Medication Error Due to Distraction and Incorrect Administration
Penalty
Summary
A medication error occurred when a nurse administered the medications intended for one resident to another resident. The nurse was preparing medications for two residents at the same time and typically labeled the medication cups with the residents' names. However, during this medication pass, the nurse accidentally grabbed the wrong cup and gave the incorrect medications to the resident. The nurse realized the error immediately after administration. The resident who received the wrong medications had a medical history that included end-stage renal disease, respiratory syncytial virus pneumonia, generalized anxiety disorder, pulmonary hypertension, and dependence on renal dialysis. The resident was cognitively intact at the time of the incident. After receiving the incorrect medications, the resident appeared lethargic and sleepy, prompting the facility to send the resident to a local hospital for evaluation, where no treatment was required. Interviews with staff revealed that interruptions during medication passes, such as questions from other residents and the presence of a student, contributed to the error. The nurse involved reported being distracted and stated that the pre-popping method of preparing medications, which was not taught by the facility, was used to expedite the medication pass. The Director of Nursing and another RN both identified that the administration of certain medications, such as Losartan Potassium, could have had significant negative outcomes.