Medication Error Due to Resident Misidentification
Penalty
Summary
A medication error occurred when a medication aide administered a set of medications intended for one resident to another resident with severe cognitive impairment. The aide had previously given the correct morning medications to the resident, but later, due to changes in the resident's appearance and a case of mistaken identity, she addressed the resident by another's name and administered the wrong medications. The aide realized the error about an hour later and reported it to the nurse on duty. The resident who received the incorrect medications had a complex medical history, including hypertensive heart disease with heart failure, atrial fibrillation, and dementia with behaviors. The medications erroneously administered included multiple antihypertensives, an antipsychotic, an antidepressant, an antibiotic, and other medications not prescribed for her. At the time of the error, the resident was alert, at her baseline, and did not exhibit any acute distress or adverse reactions, though her blood pressure was monitored and found to be slightly low but stable. The incident was confirmed through interviews with the medication aide, the nurse, the nurse practitioner, and the medical director, as well as a review of the resident's medical records, EMS, and hospital documentation. The facility's DON stated that staff are expected to follow the six rights of medication administration, which were not adhered to in this case, resulting in the administration of another resident's medications to the wrong individual.