Last week on the CMSCG Blog, we reviewed the majority of the regulatory requirements and Interpretive Guidance (IG) for F760 regarding Significant Medication Errors. The IG also provides examples of what can contribute to the significance of a med error, as well as medication errors that would be considered “significant” errors regardless of the resident’s status.
As you could tell from the actual survey citation examples we provided in our last post, some medication errors have a high potential for creating problems for the type of person who is living in a nursing home. One factor in determining significance is based on accepted clinical standards of practice, so certain errors are more problematic than others. The Interpretive Guidance provides the following examples of significant medication errors:
Significant Medication Error if Med Omitted:
- Furosemide (diuretic) ordered 40mg 2x/day – not administered at least once
- Metoprolol Succinate (beta-blocker) ordered 100mg daily – not administered at least once
It is clear that omissions of these types of medications, versus non-significant “vanilla” type med errors, such as not administering a fiber packet or calcium chewable, both of which are examples provided in the IG, would have different outcomes. Speaking of fiber, however, the IG does state that forgetting fiber once is one thing, but if you forget it multiple times and the resident had a negative outcome, such as constipation for multiple days, then it could be time for the surveyor to think about the significance of the error.
Significant Medication Error if Administered without a Physician’s Order:
- Allopurinol (xanthine oxidase inhibitor)
- Amoxicillin (antibiotic)
- Warfarin (anticoagulant)
Significant Medication Error if Wrong Dose Administered:
- Digoxin (cardiac glycoside) ordered 0.125mg daily – administered .25mg
- Morphine Sulfate ordered 20mg/ml 0.25ml – administered .5ml
The IG discusses how medications with a Narrow Therapeutic Index (NTI) could be impacted by even a single med error. Digoxin is one of those medications listed. The rest of the list includes: warfarin (noted above), lithium salts, theophylline, carbamazepine, and phenytoin (discussed below).
Significant Medication Error if Administered via Wrong Route:
Neomycin and Polymyxin B (antibiotic) Ear Drops ordered 4-5 drops to left ear 4x/daily – administered to left eye
Significant Medication Error if Wrong Dosage Form is Administered:
Parke-Davis Dilantin Kapseals (anticonvulsant) 100mg ordered 3 Kapseals by mouth at bedtime – administered Prompt Phenytoin 100 mg 3 capsules by mouth at bedtime. The IG notes that the Kapseals have an extended rate of absorption versus the capsules, which is the reason for the significance of the error.
Significant Medication Error if Wrong Medication is Administered (LASA meds):
Vibramycin (antibiotic typically used for bacterial infections) ordered – administered Vancomycin (antibiotic typically used for MRSA infections)
Significant Medication Error if Administered at Wrong Time:
- Oxycodone 5mg ordered 2 Tabs 20 minutes before painful treatment – administered 2 tabs after treatment
During a standard recertification survey, the facility will be providing the survey team with a schedule of medication administration times as part of the Entrance Conference form. You are also responsible for populating the CMS-802 Matrix for Providers, where you will identify residents who are receiving any of the following medications:
Surveyors will use the Medication Administration Observation pathway to observe staff on different units and different shifts, as well as multiple routes of administration. Even one significant med error can lead to a citation at F760 – so be aware of the potential for a deficient practice to be identified during medication administration.
A reminder again, Nursing Administration needs to assess the frequency of medication administration observations being conducted by the Staff Development to evaluate the competency of the licensed nurse assigned to perform this duty. Also remember that if you are assigning competency evaluations to be completed by the RN Supervisors or Nurse Managers, when was the last time that they can a competency in this area completed?