Significant Medication Error Due to Improper Medication Administration and Labeling
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for one resident to another. The error took place after the RN prepared two medication cups for two residents with similar first initials, labeling the cups with only initials. The RN placed one cup in the medication cart drawer while the resident was being assisted by CNAs, then later mistakenly administered the wrong cup to the resident. The nurse realized the error during administration but had already given the medications. The affected resident had a history of heart failure, hypertension, diabetes mellitus, and depression, and was cognitively intact. The resident received eight medications not prescribed to her, including drugs for blood pressure, diabetes, cholesterol, and an antipsychotic. Following the error, the resident was transferred to the emergency department for monitoring due to concerns about potential adverse effects, such as hypotension. The resident reported mild dizziness and dry mouth upon arrival at the hospital, where she was monitored and later discharged back to the facility. The facility's investigation revealed that the nurse did not notify the resident's family about the transfer or the medication error, and there was no documentation showing that the resident was asked about family notification. Additionally, the facility's policy prohibits saving medication cups in the medication cart, and the nurse's method of labeling contributed to the error. No audits or monitoring of medication administration were conducted following the incident, and only the involved nurse received education regarding the error.