Significant Medication Error: Lisinopril Administered Despite Low Blood Pressure
Penalty
Summary
A significant medication error occurred when a resident with a history of Type II Diabetes, Alzheimer's Disease, schizoaffective disorder, and anxiety, who was cognitively impaired with a BIMS score of 4, was administered Lisinopril despite a documented systolic blood pressure of 89/54 mmHg. The physician's order clearly stated that Lisinopril should be held if the systolic blood pressure was under 100 mmHg and the provider should be notified. The medication was administered by a licensed nurse during the morning medication pass, contrary to the order and facility policy. Following the administration, the resident experienced hypotension with blood pressure readings dropping as low as 77/45 mmHg. The resident was found on the floor by a CNA, assessed for injury, and subsequently transferred to the emergency department as ordered by an advanced practice nurse. There was no documentation that normal saline was administered via IV prior to the transfer, as ordered. The Director of Nursing confirmed the medication error and the lack of IV administration before hospital transfer.