The instructions on the MAR, on the medication bottle and on the referral form for this person were all different. Although the instructions were different enough in wording and readability to create misinterpretation, they were not directly conflicting. For example, the dosage and timing in relation to other PRNs and possible interactions were not fully outlined on each in the same way.  This explains why the confusion may not have been caught despite staff triple checking the instructions each time they administered medications.

Adding to the potential confusion was that the PRN medication was also prescribed as part of the person’s daily regimen, meaning that in addition to the instructions that it was a daily medication, the PRN was also instructed to be given as needed, but instructions did not specify a timeframe for administering after the daily dose was administered.