Medication Error Due to Failure to Follow Identification Procedures
Penalty
Summary
A medication error occurred when a resident, who was cognitively intact and had diagnoses including cerebral infarction, morbid obesity, and chronic pain syndrome, was administered her roommate's medications instead of her own. The error took place when an LPN prepared the roommate's medications, entered the resident's room, and, after verbalizing the roommate's name, gave the medication cup to the resident who responded. The resident questioned the number of pills, as it was more than she typically received, but ultimately took the medication. The LPN later realized the mistake after verifying the medications and confirmed that the wrong medications had been administered. Facility documentation and interviews confirmed that the medications given in error included Doxepin, Tylenol, Famotidine, Gabapentin, and Senna. The resident did not experience any adverse reactions following the incident. The error was identified and reported immediately to the appropriate staff, including the nurse practitioner, administrator, and director of nursing. The facility's policy required verification of resident identity and medication details prior to administration, but these procedures were not followed, resulting in the medication error.