Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's prescribed medications—morphine sulfate and lorazepam oral concentrate—to a cognitively intact resident with multiple chronic conditions, including diabetes, chronic kidney disease, heart failure, COPD, chronic respiratory failure, and chronic pancreatitis. The nurse failed to verify the resident's identity, did not explain the medications being administered, and did not confirm the resident's name prior to administration. The nurse was running behind on the medication pass and, in haste, called out the intended recipient's name, to which the wrong resident responded, and then administered the medications without further verification. Shortly after receiving the incorrect medications, the resident experienced nausea and a rapid decline in condition, including changes in vital signs and mentation. The resident reported that the nurse did not communicate or identify herself, nor did she provide any information about the medications being given. The error was discovered when the resident questioned what had been administered and another nurse intervened to monitor the resident's condition. The facility's medication administration policy required verification of resident identity and adherence to the seven rights of medication administration, including the right resident, right medication, and right dose. The nurse involved admitted to not following these protocols due to being in a hurry. The incident resulted in the resident requiring administration of Narcan and transfer to the hospital for further evaluation.