Medication Administration Error: Resident Given Another's Medications
Penalty
Summary
A medication administration error occurred when a resident was given another resident's evening medications. The facility's policy required medications to be administered safely, timely, and as prescribed, with errors documented and reviewed. On the evening in question, a medication aide reported missing medications for one resident, which led to the discovery that those medications had been administered to a different resident in error. The medications given in error included duloxetine, melatonin, clozapine, dicyclomine, and metformin. The resident who received the wrong medications had diagnoses including anxiety disorder, major depressive disorder, diabetes mellitus, and bipolar disorder. Following the error, the resident was assessed and found to be alert and oriented, with stable vital signs and no immediate adverse reactions observed. The error was identified after the medication aide and nursing staff reviewed the medication cart and administration records, realizing that the medications intended for one resident had been given to another. Interviews with staff revealed that medication administration procedures included verifying resident names, photos, and medication orders. However, staff involved in the incident were initially unaware of the error until the discrepancy was investigated. Documentation of the incident was initially incomplete, lacking details about which medications were given in error and to whom, and was later amended to include this information.