Significant Medication Error Due to Resident Misidentification
Penalty
Summary
A significant medication error occurred when a nurse administered medications intended for another resident to an 83-year-old resident with dementia, epilepsy, and dysphagia. The nurse, who was unfamiliar with the unit and the residents, failed to properly identify the resident before administering Lisinopril, Metformin, Seroquel, and Ramelteon—none of which were prescribed for the resident. The nurse did not confirm the resident’s identity using a photo in the electronic medication record (EMR) or a name on the door, as both were missing for this resident. The nurse addressed the resident by another resident’s name, and the resident’s representative did not correct her, leading to the administration of the wrong medications. Following the administration, the resident experienced severe hypotension and tachycardia, requiring transfer to the hospital for intravenous fluids and monitoring. The incident report and subsequent investigation revealed that the nurse realized the error only after returning to the medication cart. The nurse had not worked on the resident’s hall previously and relied on a report sheet that listed the wrong room number. The lack of proper resident identification systems, such as missing photos in the EMR and absent door nameplates, contributed to the error. It was also noted that 17 residents in the facility either did not have a photo in the EMR or a name on their door at the time of the incident. Interviews with staff confirmed that the nurse did not follow the facility’s medication administration policy, which requires verification of the resident’s identity using a photo and adherence to the six rights of medication administration. The nurse had previously made another medication error earlier in the month, which involved administering the wrong dose of a different medication. The facility’s investigation concluded that multiple system failures, including inadequate resident identification and failure to follow established procedures, led to the significant medication error and subsequent hospitalization of the resident.