How do I report a facility for making a serious medication error?

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M

MHHE1967 Asked November 2021

How do I report a facility for making a serious medication error?

My relative suddenly and unexpectedly became combative and the facility said he/she hit someone. The person did not need medical care, The facility called the police, who talked to my relative until he/she calmed down. Later, he/she became very agitated and the staff called for an ambulance. He/she was taken to the ER, and the outcome was that the facility had mistakenly been giving him/her a smaller dose of medicine than prescribed to keep him/her calm, according to the hospital doctor.

I believe that this incident never would have happened if the medication error had not been made. I don’t yet know how long my relative had been under-dosed.

I want to report the facility to the state, but I don’t know to whom or what kind of documentation they might need, other than hospital discharge papers. Has anyone else dealt with this? What steps did you take, specifically?

Alzheimer's & Dementia Elder Law Long Term Care Medication Management

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score 2 · Answer 1

I would first talk this over with the facilities DON in person. The AL my Mom was in the Nurse handled the ordering of prescriptions. She should have the doctors order on file and the medication from the pharmacy so the label and the order match. If they do, then you ask why ur relative was being given less than ordered? They should have a record when the med was given and the name or initials of the LPN or medtech next to the time. And all should be in different handwriting.*

My daughter found out on her shift, that the pharmacy had made an error in filling the prescription and that in 2 shifts before her it wasn't caught. This was a No No on the pharmacies part because no prescription should go out without a Pharmacist signing off. They have pharmacy techs that fill the order. That pharmacy lost the facilities business. They were at fault.

I would wonder what the facilities procedures are concerning meds. When they are delivered, is the prescription checked with the order to make sure its correct by an RN? Or, are they placed on the med cart for the LPN or Medtech to verify the med and dosage is correct?

You have different people doing med passes. You have staff that work 5 days a week, others just weekends. Some may work 8hr shifts, others 12. So the same person is not giving your family member her meds. If this is a pharmacy error, yes IMO it should have been caught.

*again my daughter noticed that the med sheet was in the same handwriting for all the med passes. She recognized the handwriting and confronted the other LPN. His excuse was he spilt coffee on the original so he rewrote it. What actually happened was he was stealing the patients meds and rewrote the sheet to cover it up. My daughter reported him.

So, there can be all kinds of reasons why your relative was not given the prescribed dosage. The ER doctor is probably going by a blood test which is showing that there isn't enough med in her system for the dosage and frequency she should have received it. Maybe the dosage is correct but she is not getting it on times precribed. Maybe she is, but keeping it in her mouth and when the Medtech/LPN leaves the room, spits it out. Even with Dementia residents can be wiley.

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score 0 · Answer 2

Med errors are a big deal. It's important that the facility review them. You may also want to do this: If the facility has an online web portal there may be a spot on there to report this directly to the facility. This can be done anonymously, and would not 'flag' your relative's records. It will cause their Quality team to review your relative's chart and follow up with the provider, nurse manger, and pharmacy, and help prevent this from occurring to another patient.

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