65G-7.006. Medication Errors  


Effective on Monday, July 1, 2019
  • 1(1) A “medication error” is any of the following:

    10(a) Administration or supervision of self-administration of a wrong medication, including:

    211. Administration or supervision of self-administration of medication for any symptom, illness, or reason other than the one for which the medication was prescribed;

    452. Administration or supervision of self-administration of medication for which there is no current prescriber order;

    61(b) Administration or supervision of self-administration of a wrong dose, including;

    721. Administration or supervision of self-administration of an incorrect dose of medication;

    842. Administration or supervision of self-administration of more than one dose of the same medication in a scheduled time period;

    104(c) Administration or supervision of self-administration of a medication to the wrong client, which means the administration or supervision of self-administration of medication to a client that is prescribed or ordered for someone else;

    138(d) Administration or supervision of self-administration of medication via the wrong route;

    150(e) Failure to administer or supervise the self-administration of medication within 60 minutes of the prescribed dosage time;

    168(f) Failure to immediately and accurately document administration or supervision of self-administration of medication on the MAR;

    185(g) Administration or supervision of self-administration of a medication which has expired or is improperly labeled;

    201(h) Failure to conduct an accurate medication count for controlled medications;

    212(i) Failure to administer or supervise the self-administration of a medication, for any of the following reasons:

    2291. Client refused the medication;

    2342. MAP or licensed health care practitioner did not administer or supervise the self-administration of the medication;

    2513. Medication was not available;

    2564. New order not initiated within 24 hours;

    2645. Refill not ordered timely;

    2696. Insurance issue;

    2727. Pharmacy issue;

    2758. Family error;

    2789. Other not given;

    282(j) Administration or the supervision of self-administration of medication by a MAP not validated as required by rule 30065G-7.004, 301F.A.C.

    302(2) Immediately following an error as listed in subsection (1), the MAP, licensed health care practitioner, or facility administrator must take the following steps:

    326(a) Notify supervisory personnel;

    330(b) In the case of administration of a wrong medication, a wrong dosage, or the provision of medication to the wrong client, immediately notify the client’s health care practitioner, observe the client closely for a minimum period of 60 minutes after the medication was administered or self-administration was supervised, or for as long as directed by the health care practitioner, and immediately report any observed changes in the client’s condition to the prescribing health care practitioner, and call 911 to request emergency services if the client exhibits respiratory difficulty or other potentially life-threatening symptoms;

    424(c) For all errors listed in subsection (1), with the exception of paragraphs e., f., g., h., and j., notify the client’s prescribing health care practitioner of the error, and if there is no licensed health care professional present, request that the practitioner prepare and electronically transmit via fax or secure email a medication directive addressing the error to the client’s home, facility, or pharmacy, and document the client’s health care practitioner’s response or lack of response; and

    502(d) Fully document all observations and contacts made regarding a medication error in a “Medication Error Report,” APD Form 52265G-7.006 523A, effective April 2019, incorporated herein by reference, which may be obtained at 536http://www.flrules.org/Gateway/reference.asp?No=Ref-10598538. The MAP or licensed health care practitioner shall place a copy of the Report in the client’s file. It is permissible to use an alternate Medication Error Report form generated by an electronic system, provided that the alternate electronic form collects all the information required and collected on the Agency form.

    590(3) If a medication error occurs in a facility, the MAP or licensed health care practitioner must:

    607(a) Submit the Medication Error Report to the facility administrator and to the Regional Office within 24 hours of discovering the error; and

    630(b) Maintain a copy of the report in the client’s record and also with the MAR for review.

    648(4) If a medication error occurs in a client’s home, the MAP or licensed health care practitioner who committed the error must:

    670(a) Submit a Medication Error Report to the Regional Office within 24 hours of discovering the error;

    687(b) Maintain a copy of the report in the client’s record and with the MAR for review.

    704(5) If a discrepancy in the accounting of a controlled substance occurs following a medication count, the MAP or licensed health care practitioner must report the discrepancy within 24 hours following discovery of the error to:

    740(a) The Regional Office; and

    745(b) The MAP’s or licensed health care practitioner’s supervisor, if applicable.

    756(6) If an Agency MCM determines that the medication error justifies corrective action, the Regional Office will notify the MAP, licensed health care practitioner, or his or her supervisor in writing of the necessary corrective action plan, including a specific and reasonable timeframe for completion of the corrective action plan. If the MAP or licensed health care practitioner fails to comply with the corrective action plan, the Agency may take action against:

    828(a) The MAP’s validation, including prohibiting the MAP from providing medication administration services; or

    842(b) The provider’s residential facility license, and

    849(c) The provider’s Medicaid Waiver Services Agreement.

    856Rulemaking 857Authority 858393.501, 859393.506 FS. 861Law Implemented 863393.506 FS. 865History–New 3-30-08, Amended 7-1-19.