Significant Medication Error Leads to Resident Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with a history of atrial fibrillation, heart disease, anemia, and a recent right femur fracture was admitted to the facility following hip surgery. The resident had physician orders for several medications, including buprenorphine-naloxone sublingual film for narcotic dependence and tramadol for pain. However, naloxone (Narcan) nasal spray, which was not ordered for the resident, was received from the pharmacy and placed in the medication cart. On the evening following admission, an LPN administered tramadol and then, in error, administered the naloxone nasal spray instead of the prescribed buprenorphine-naloxone sublingual film. The LPN noted the difference in medication forms but proceeded with the administration. Shortly after, the resident exhibited symptoms including feeling hot, trembling, and had a significant change in blood pressure. The resident was subsequently sent to the hospital for evaluation and treatment due to altered mental status and was admitted to the ICU with cardiogenic shock and acute cystitis. Interviews with facility staff and the pharmacist confirmed that naloxone was not intended to be administered and was not part of the facility's medication orders for the resident. The error was attributed to confusion between the naloxone nasal spray and the prescribed buprenorphine-naloxone film, as well as a failure to follow medication administration protocols, including verifying the correct medication and route. Facility policy required strict adherence to the six rights of medication administration and label checks, which were not followed in this instance.