Medication Administration Error Involving Two Residents
Penalty
Summary
Two residents with severe cognitive impairment were involved in a significant medication error when a registered nurse, while administering medications, became distracted by a conflict in the hallway. The nurse accidentally mixed up unlabeled medication cups and administered the wrong medications to each resident. One resident, with diagnoses including unspecified dementia, psychotic disturbance, anxiety disorder, and atrial fibrillation, received another resident's medications, which included donepezil. The other resident, also with severe cognitive impairment and diagnoses of dementia, psychotic disturbance, altered mental status, and muscle weakness, received medications intended for the first resident, including acetaminophen, valproate, and apixaban. The incident was documented in the residents' progress notes, with the nurse acknowledging the error and specifying the medications that were incorrectly administered. The facility's policy defines a medication error as the preparation or administration of drugs not in accordance with physician's orders, manufacturer specifications, or accepted professional standards. The error was identified and reported to facility leadership, and the event was investigated as a significant medication error involving two residents during a medication pass.