Medication Error: Incorrect IV Antibiotic Administered
Penalty
Summary
A deficiency occurred when a nurse administered the incorrect intravenous (IV) antibiotic medication to a resident who had been admitted with multiple serious infections, including a peritoneal abscess, sepsis, bacteremia, and pneumonia. The resident, who had intact cognition, was prescribed Daptomycin for IV therapy following a recent hospital stay for MRSA bacteremia. On the day of the incident, the nurse brought two IV medication bags into the resident's room—one intended for the resident and another for a different patient. The nurse verified the resident's identity but failed to verify the medication itself, resulting in the administration of Ceftin, which was not ordered for the resident, instead of the prescribed Daptomycin. The error was identified by the nurse within minutes, and the infusion was stopped shortly after it began. Review of the resident's orders confirmed that only Daptomycin was prescribed, with no order for Ceftin. Interviews with facility staff, including the nurse involved, the unit manager, and the director of nursing, confirmed that the facility's medication administration policy and the five rights of medication administration were not followed in this instance. The facility's policy requires verification of the medication against the electronic medication administration record (EMAR) prior to administration, which was not completed as required.