Medication Error: Resident Administered Roommate's Medications
Penalty
Summary
A nurse administered the incorrect medications to a resident by giving her the medications intended for her roommate. The medications given in error included acetaminophen 325mg, senna 8.6mg, trazodone 50mg, and extended release morphine 15mg. The incident was documented in the resident's medical record, and the nurse notified the physician, who provided instructions to hold the resident's scheduled Tylenol, senna, and trazodone. The nurse also contacted the resident's emergency contact and initiated monitoring for any adverse effects. Following the medication error, nursing staff conducted additional assessments each shift to monitor the resident for any changes in condition. Throughout the monitoring period, the resident's condition remained at baseline with no noted changes. The nurse involved reported the error to the nurse manager and followed instructions to check for allergies and perform neurological checks. The incident was the only medication error reported in the facility within the past 60 days.