Significant Medication Error Resulting in Resident Harm
Penalty
Summary
A significant medication error occurred when a registered nurse administered the wrong medications, including amiodarone, to a resident who was not prescribed this medication. The resident, who had a history of high blood pressure, schizophrenia, and weakness, began experiencing mild chest pain and shortness of breath after receiving the incorrect medication. The nurse immediately recognized the error, assessed the resident, obtained vital signs, and notified a supervisor. The resident was subsequently transferred to the emergency department for further evaluation and monitoring due to the acute symptoms following the medication error. Review of the resident's clinical record confirmed that amiodarone was not ordered for this individual. The nurse involved stated that she did not realize the room was shared by three people at the time of administration and attempted to double-check herself. The facility's documentation indicated that the nurse was suspended pending investigation and later resigned. The incident was identified as actual harm for past non-compliance, as the resident required hospital transfer due to the medication error.