Significant Medication Error Due to Nurse Distraction
Penalty
Summary
A medication error occurred when a nurse administered another resident's medications to Resident #10, who had diagnoses including hypertension, diabetes, stroke, and depression, and was assessed as cognitively intact and independent with most activities of daily living. The incident took place during a medication pass when multiple residents were present at the medication cart, asking questions, which distracted the nurse. As a result, Resident #10 received Depakote 125 mg, Seroquel 50 mg, and vitamin D3 25 mcg, which were not prescribed to her. Following the administration of the incorrect medications, Resident #10 became lethargic and experienced confusion, as reported by both the resident and documented in the medical record. The facility's incident report confirmed the error and noted a change in the resident's condition, specifically lethargy for the majority of the shift. The facility's medication administration policy emphasized the importance of verifying the right resident and right medication, and cautioned against interruptions during medication passes, but these procedures were not followed at the time of the incident.