Resident Administered Another Resident's Medications Due to Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple chronic conditions, including type 2 diabetes, atrial fibrillation, heart failure, chronic kidney disease, hypertension, gout, dysthymic disorder, and insomnia, was administered medications intended for another resident. The error was made by an agency LPN, who gave the resident Lisinopril 40 mg, Duloxetine 60 mg, and Bupropion 300 mg ER, none of which were prescribed for this resident according to the computerized physician orders. The resident recalled being informed by the facility about the error and reported experiencing dizziness, stomachache, and inability to eat for 24 hours following the incident. The facility's documentation confirmed that the LPN notified the physician, DON, and the resident's representative after the error was discovered. The resident's vital signs were checked and found to be within normal limits, and the progress note indicated no discomfort or adverse reaction at the time of assessment. The DON, who had just started working at the facility the day before the incident, confirmed the details of the medication error and identified the agency LPN as the individual responsible for administering the wrong medications.