Medication Error Due to Failure to Confirm Resident Identity
Penalty
No penalty information released
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Summary
A licensed nurse administered propranolol and losartan, medications intended for another resident, to Resident 1 after mistakenly identifying them as a different individual. Resident 1, who had diagnoses including heart failure and atrial fibrillation, did not have physician orders for either propranolol or losartan. The error was discovered and documented by the nurse, who noted that Resident 1's blood pressure at the time of administration was 92/55. Facility policy required confirmation of resident identity prior to medication administration, but this step was not followed, resulting in the medication error.