{"report_id":241,"form_id":"23","user_id":81,"organization_id":10,"question_id":"98","question_type":"Free_Text","text_answer":"The DSP has worked in this capacity for approximately 5 years and reports this is her first med error.  She describes the day of the incident (8\/16\/19) as \u201cbusy\u201d, with 1 of the four residents on an outing with the other staff person on duty.  The DSP volunteered that she was preparing meds for one resident at a time.  After signing the medication log for the resident in question, she noticed that one of the medications was different in color and realized the dosage was different (300 mg vs. his usual dosage of 200 mg) and notified the supervisor.  The supervisor instructed the DSP to look in the \u201coverflow\u201d medications and see if there were meds there until the meds could be re-ordered.  The DSP was able to administer the correct medication dosage from the resident\u2019s \u201coverflow\u201d meds. However, the DSP had already initialed the med log when she pulled the incorrect dosage.  The supervisor notified the nurse and the correct dosage was ordered because there were not enough meds in overflow for more than one more day.  During her next shift, two days later, the DSP again signed the med log and then noticed the new medication bubble packs were still the wrong dosage. She again notified the house supervisor who worked with the nurse and the pharmacist to make the correction and get the correct dosage.  The DSP reports that the time lapse between the time she first noticed the incorrect dosage and when it finally arrived was no more than 4-5 days.  Because there were meds in the overflow, the resident only went without the medication a 2-3 day (not the 30+ days indicated on the CEP Report) and never received more than prescribed dosage.","created_by":81,"updated_by":81,"updated_at":"5\/25\/2021 9:30:24 am","created_at":"5\/25\/2021 9:30:24 am","id":14827}