Medication Error: Wrong Drug Applied to Wound
Penalty
Summary
A medication error occurred when a licensed nurse administered the wrong medication to a resident with a history of bullous pemphigoid, a rare skin condition causing large fluid-filled blisters. The resident, who was cognitively intact, had a physician's order for topical metronidazole to be applied to a wound on the right arm. Instead, the nurse mistakenly applied crushed methadone tablets to the wound after failing to locate the prescribed medication in the treatment cart. The error was discovered when the nurse returned to the medication cart and realized the incorrect medication had been used. Interviews and record reviews revealed that the nurse did not properly verify the medication label or follow the facility's policy requiring the five rights of medication administration. The facility's policies specify that medications must be administered according to prescriber orders and that the label should be checked three times to ensure accuracy. The nurse acknowledged the mistake and stated that she should have checked the drug name, dose, resident's name, frequency, time, and route before administration.