Medication Administration Error: Wrong Resident Received Unordered Medication
Penalty
Summary
A medication administration error occurred involving a resident with medical diagnoses including pulmonary hypertension, autonomic nervous system disorder, left hemiplegia, and atrial fibrillation. The resident, who was cognitively intact and required varying levels of staff assistance for daily activities, was mistakenly given Meclizine via PEG tube, a medication for which there was no physician order in the resident's medical record. The error was documented on a communication form and a facility medication error report, both indicating that the medication was intended for the resident's roommate, but was administered to the wrong individual. The facility's policy on medication administration requires staff to cross-check the physician's order, medication administration record, and drug container label to ensure accuracy. Despite these procedures, the nurse administered the medication to the incorrect resident after the roommate requested it. The incident was confirmed through interviews with the resident and the facility administrator, as well as through review of the medical record and facility documentation. The resident reported experiencing some dizziness following the error but had no lasting effects.