Failure to Ensure Five Rights of Medication Administration Results in Medication Error
Penalty
Summary
The facility failed to ensure the five rights of medication administration, resulting in a medication error involving one resident. According to the facility's policy, medications are to be administered at the time they are prepared, and residents must be positively identified before administration. However, a certified medication aide prepared medications for two residents who both required their medications to be given with applesauce. While allowing a potassium tablet to dissolve in applesauce for one resident, the aide prepared another resident's baclofen, also with applesauce. The aide then mistakenly administered the baclofen intended for one resident to another resident, as the correct medication cup containing the potassium tablet remained in the cart. The incident was immediately reported to the nurse, and the resident who received the incorrect medication was assessed. The nurse noted that the resident's oxygen levels were at their baseline and that there were no other symptoms observed during monitoring. The medication aide described their usual process for medication administration, which includes checking the medication three times, but acknowledged the error occurred when they were interrupted by a resident's request. The Director of Nursing confirmed the sequence of events and the identification of the medication error.