Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A medication error occurred when a nurse administered an antidepressant, diuretic, hypoglycemic, and blood pressure medications to a resident that were prescribed for another resident. The nurse entered the resident's room, called him by the wrong name, and did not verify his identity before pulling and administering the medications. The resident was cognitively intact and had multiple diagnoses, including parkinsonism, type 2 diabetes, chronic kidney disease, hypertension, and a history of myocardial infarction. The nurse reported feeling overwhelmed and, after returning to the medication cart, mistakenly selected and administered the medications intended for a different resident. The error was discovered when the nurse called the resident by the wrong name after administering the medications, prompting the resident to correct her. The nurse immediately recognized the mistake, assessed the resident's vital signs, and notified the physician and DON. The medications administered in error included Lexapro, Lasix, Jardiance, Lisinopril, Metoprolol ER, and Prednisone, none of which were part of the resident's prescribed regimen for that time. The resident's regular morning medications were held except for Carbidopa-Levodopa. Interviews with facility staff, including the nurse, NP, DON, and Medical Director, confirmed that the nurse did not follow proper identification procedures before medication administration. The nurse did not ask the resident to state his name, despite the resident being alert, oriented, and a new admission. The incident was attributed to confusion and feeling overwhelmed, with two new admissions occurring that day. The resident experienced anxiety upon learning of the error but did not display any adverse effects or changes in vital signs following the incident.