Medication Administration Error Due to Failure to Follow Identification Protocols
Penalty
Summary
A licensed practical nurse (LPN) failed to follow professional nursing standards of practice regarding medication administration by giving one resident another resident's medications. Specifically, the LPN administered medications intended for a different resident, which included Zolpidem, to which the recipient had an allergy, and Eliquis, a blood thinner not prescribed for the recipient. The error occurred after the LPN became distracted by a resident in the hallway, stepped away from the medication cart, and upon returning, mistakenly gave the wrong medications. The LPN had labeled the medication cups with residents' first names, which were similar, and the residents' rooms were adjacent to each other, contributing to the confusion. The facility's policy outlined the five rights of medication administration, and staff were educated on the six rights, but the LPN admitted to not following these protocols during the incident. Interviews with other nursing staff confirmed the expected procedures for resident identification, including using the electronic medical record (EMR) photo, verifying the resident's name and date of birth, and matching room numbers. Despite these established procedures, the LPN did not adhere to them, resulting in the medication error. No adverse reactions were observed in the resident who received the incorrect medications.