Significant Medication Error Due to Resident Misidentification
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered potassium to the wrong resident after mishearing a telephone order from a cardiologist. The nurse, who was working on a different unit than usual, confused two residents with similar first names and last initials. Without verifying the resident's identity or confirming recent lab work, the nurse gave a STAT dose of potassium to a resident who had not had labs drawn and was not the intended recipient of the medication. The resident who received the potassium had a medical history including congestive heart failure, hypertensive heart disease with heart failure, syncope, collapse, and atrial fibrillation. After taking the medication, the resident reported not having had a blood draw, prompting the nurse to realize the error. The resident was assessed and found to be stable, but was sent to the hospital for evaluation, where lab results showed a normal potassium level. Subsequent monitoring showed potassium levels remained within a safe range. Interviews with nursing staff and review of facility policies revealed that standard procedures for verifying resident identity and reading back telephone orders were not followed in this instance. The facility's policies require verification of the resident's name and date of birth, as well as a read-back of orders to ensure accuracy, but these steps were omitted, leading to the administration of medication to the wrong resident.