Medication Error Resulting in Hospitalization Due to Staff Misidentification
Penalty
Summary
A medication error occurred involving a resident who was admitted with diagnoses including heart failure and chronic obstructive pulmonary disease. On the morning following admission, a staff LPN mistakenly administered the medications intended for the resident's roommate, which included amlodipine 10mg, benazepril 40mg, Coreg 25mg, and sevelamer 800mg. The error was made when the LPN identified the resident incorrectly, relying on the name in the room and not verifying the resident's identity with the armband or photo in the medication administration record. The resident, who was hard of hearing, received the wrong medications after confirming she needed her medication in pudding, further contributing to the misidentification. Following the administration of the incorrect medications, the resident's blood pressure dropped significantly, with documented readings as low as 50/20. The staff recognized the error after rechecking the resident's blood pressure and reviewing the medication administration. Emergency services were called, and the resident was sent to the hospital for evaluation and treatment, where she received IV fluids and monitoring for hypotension. The resident spent approximately 16 hours in the emergency room before returning to the facility. The incident was confirmed through staff interviews and documentation review.