Significant Medication Error: Wrong Medication Administered to Resident
Penalty
Summary
A significant medication error occurred when a nurse administered the wrong medication to a resident. The nurse was preparing medications for another resident when the affected resident approached and requested his medication. The nurse mistakenly gave the resident another individual's medication, specifically Clozaril (Clozapine) 150 mg, which was not prescribed for him. The error was recognized by the nurse approximately 15-20 minutes after administration, at which point the resident exhibited lethargy. The resident, who has a history of diabetes and is described as a severe brittle diabetic with rapidly fluctuating blood sugars, was sent to the emergency room for evaluation. Upon arrival at the hospital, the resident was found to be hypoglycemic and was admitted for observation due to accidental drug overdose and altered mental status. The emergency department records indicate that critical care was necessary to manage the resident's hypoglycemia and acute ingestion of the medication. The resident remained hospitalized for several days before returning to the facility. Review of the resident's physician orders confirmed there was no order for Clozaril for this individual, while another resident did have an active order for the medication. Interviews with facility staff confirmed the sequence of events, with the nurse acknowledging the error and the DON stating that the nurse did not follow the rights of medication administration, which include verifying the right medication and right resident prior to administration.