Significant Medication Error Due to Failure in Resident Identification and Verification
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's blood pressure medication, Hydralazine 30 mg, to a resident who did not have a physician's order for this medication. The nurse, who was unfamiliar with the unit, prepared the medication for the intended resident but was interrupted by another staff member. After returning to the medication cart, the nurse mistakenly identified the wrong resident on the electronic medication administration record and failed to verify the medication against the MAR before administration. The resident who received the incorrect medication had a medical history including a left femur fracture, dementia, acute diastolic heart failure, and atrial fibrillation. Following the administration of Hydralazine, the resident became lethargic, had difficulty standing, and was found to have hypotension with a blood pressure reading of 84/46 mm Hg. The resident's spouse noticed the change in condition and suspected a medication error, prompting staff to investigate. Upon assessment, it was confirmed that the nurse had given the wrong medication. The resident required treatment, including intravenous fluids and increased monitoring, until their blood pressure stabilized. The incident was documented, and the nurse acknowledged not following proper medication administration procedures, including verifying the resident's identity and cross-checking the medication with the MAR.