Medication Error Leads to Resident Harm Due to Pre-Prepared Medications
Penalty
Summary
A resident with moderate cognitive impairment and multiple medical diagnoses, including hypertension, diabetes, and dementia, was administered another resident's medications during a morning medication pass. The nurse responsible for medication administration had prepared multiple residents' medications in advance, labeling the medication cups with initials and storing them in the medication cart drawer. Due to a mislabeling error, the nurse gave the resident the wrong set of medications. Following the administration of the incorrect medications, the resident experienced an unwitnessed fall, resulting in a laceration above the left eyebrow. The resident was subsequently sent to the emergency department for evaluation. Clinical documentation indicated that the resident developed tachycardia and hypertension after receiving the wrong medications, which included high doses of blood pressure and seizure medications not prescribed for her. The emergency department performed diagnostic tests and provided monitoring instructions due to the risk of adverse effects from the medications ingested. The nurse involved acknowledged the error, stating that she had pre-prepared medications for multiple residents, which was not in accordance with facility policy. The consultant pharmacist reviewed the incident and confirmed that the combination and dosage of medications administered in error were significant and likely contributed to the resident's fall and subsequent symptoms. The facility's policy required medications to be prepared for one resident at a time and prohibited pre-pouring or pre-setting medications.