Medication Error on Discharge Leads to Resident Harm
Penalty
Summary
A medication error occurred when a resident was discharged from the facility and sent home with another resident's medications, including a blood pressure-lowering agent not prescribed to her. The discharge documentation lacked verification of medication reconciliation, and the education provided to the resident was limited to paper handouts without verbal instruction. The resident, who had intact cognition and no memory concerns, assumed the medications were intended for her and ingested approximately 11 doses of the incorrect medications at home. As a result of taking the wrong medications, the resident experienced multiple falls at home, including one that caused acute facial trauma requiring sutures. She was hospitalized for orthostatic hypotension, which was likely exacerbated by the unprescribed blood pressure medication. Clinic records confirmed that the medication error contributed to her low blood pressure and subsequent hospital admission. Interviews with facility staff revealed that the discharge process involved sending all medications in the facility belonging to the resident, but there was no thorough review to ensure the medications matched the resident's current orders. The discharge summary and medication list were incomplete, and the error was only discovered after the resident's follow-up clinic visit, where medications labeled for another resident were identified and destroyed.