Description of Event or Problem · 1
DESCRIPTION: THE FACILITY RECEIVED A PRESCRIPTION FOR MAXORB AG PLUS 4X4.75. HOWEVER, THE PT DID NOT HAVE ORDERS FOR THIS MEDICATION. THE ORDERS WERE FOR A PT AT THE SAME FACILITY. INVESTIGATION RESULTS: AFTER REVIEW OF THE ABOVE ISSUES, THE FOLLOWING WAS DETERMINED. TYPE OF MEDICATION ERROR: INCORRECT PT. WAS THE MEDICATION ADMINISTERED TO THE RESIDENT: NO. AREA WHERE ERROR OCCURRED: DATA ENTRY. INITIAL REVIEW MEDICATION(S)/PRODUCT(S) INVOLVED: MAXORB AG PLUS 4X4.75. ORDER ERROR POTENTIAL: HIGH. ROOT CAUSE: MULTIPLE PT ORDERS WERE SUBMITTED ON ONE SHEET FROM THE FACILITY. THE DATA ENTRY TECH DEVIATED FROM ESTABLISHED POLICY AND PROCEDURE BY NOT VERIFYING TWO POINTS OF IDENTIFICATION. TWO POINTS OF IDENTIFICATION WERE PRESENT ON THE ORDER. THE PHARMACIST DEVIATED FROM ESTABLISHED POLICY, AND PROCEDURE AND APPROVED THE ORDER AS CORRECT. (B)(6). MEDICATION ADMINISTERED TO OR USED BY THE PT: NO. WHERE DID THE ERROR OCCUR: LONG TERM CARE FACILITY. TYPE OF STAFF MADE INITIAL ERROR: PHARMACY TECH. WERE OTHER PRACTITIONER(S) INVOLVED (PERPETUATE) IN THE ERROR: YES, PHARMACIST. SEVERITY: ERROR REACHED PT; NO PT HARM.