Significant Medication Error Due to Resident Misidentification
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered medications intended for one resident to another. The LPN, who was new to the unit and working as agency staff, parked the medication cart between two residents' rooms, prepared medications for a resident with diabetes and other chronic conditions, but mistakenly entered the room of a different resident. The LPN informed the resident that medications and insulin were to be administered, and the resident consented. Upon returning to the medication cart, the LPN realized the error and immediately reported it to the Nurse Manager. The resident who received the incorrect medications had diagnoses including schizophrenia, dementia, congestive heart failure, and chronic obstructive pulmonary disease, and was not prescribed insulin. The medications administered included both long- and short-acting insulin, psychotropic, and antihypertensive drugs, none of which were prescribed for this resident. Following the administration, the resident exhibited asymptomatic hypoglycemia and hypotension, with vital signs showing low blood pressure and heart rate, as well as fluctuating blood glucose levels. The resident was lethargic and dizzy, with intermittent confusion, which was noted as baseline due to advanced dementia. The facility's policy required staff to verify the right medication, dosage, time, and method of administration, and to ensure medications ordered for one resident are not given to another. The LPN failed to correctly identify the resident before administering the medications, leading to the error. The incident was discovered and reported promptly, and the resident was closely monitored and treated for the effects of the medication error.