Medication Error: Administration of Wrong Medication to Resident
Penalty
Summary
A medication error occurred when Nurse #1 administered Ativan, a medication prescribed for a different resident, to Resident #60, who was not prescribed Ativan and did not have a diagnosis of anxiety. Resident #60 had orders for Oxycodone 5 mg for pain management, but instead received Ativan 0.5 mg, which was intended for another resident. The error was discovered during the narcotic count at shift change, revealing that the wrong medication had been pulled and administered. Nurse #1 acknowledged that she failed to verify the medication label before administration, mistakenly assuming the last medication card in the narcotic lock box was the correct one for Resident #60. Resident #60 was cognitively intact and had diagnoses of diabetes type 2, hypertension, and atrial fibrillation. There were no orders for antianxiety medication for this resident, and the Minimum Data Set assessment confirmed no receipt of such medication. The incident was identified promptly, and the error was reported to the Director of Nursing, the former Medical Director, and Resident #60. The error resulted in Resident #60 not receiving the scheduled dose of Oxycodone as ordered, and receiving Ativan instead.