Medication Error Due to Improper Administration and Communication
Penalty
Summary
A significant medication error occurred when a resident with a history of cerebral infarction and hypertension was administered medications intended for her roommate, who had diagnoses of hemiplegia and hemiparesis following cerebral infarction. The error took place during a medication pass when a nurse (LN 3) prepared medications for one resident and handed them to another nurse (LN 4), who was in training. Due to miscommunication, LN 4 administered the medications to the wrong resident, resulting in the resident receiving 17 medications not prescribed for her, including blood pressure medications, blood thinners, seizure medications, pain medications, and others. Interviews with nursing staff revealed that the standard procedure for medication administration was not followed. LN 3 admitted to preparing medications and giving them to another nurse to administer, a practice she had observed but was not consistent with facility policy. LN 4, a new graduate nurse, misunderstood instructions and administered the medications to the wrong resident. Both nurses failed to verify the resident's identity and did not adhere to the five rights of medication administration (right resident, right drug, right dose, right route, right time). The facility's policy clearly states that medications must be administered by the individual who prepares them and that resident identity must be verified before administration. The incident was confirmed through interviews, record reviews, and observation, with the resident who received the wrong medications reporting no awareness of the error and no change in condition at the time of the survey. The error was reported to facility leadership and the consultant pharmacist, who confirmed the risk associated with the medications administered.