Resident Harm from Unattended Medication Error
Penalty
Summary
A significant medication error occurred when a resident with liver cirrhosis and stage 3 kidney disease ingested a 10mg Zyprexa pill that was not prescribed to them. The medication, intended for another resident, was left unattended in a cup on top of the medication cart by a licensed nurse who had stepped away. The resident took the medication while at the cart for their own bedtime medications. Shortly after, the resident became unresponsive, began mumbling incoherently, and was transferred to the emergency room, where they required intensive care and mechanical ventilation for several days. Interviews with staff revealed that standard procedures required medications to be kept locked in the cart and not left unattended, and resident identification was to be verified before administration. However, in this incident, the medication was left accessible, and the nurse provided inconsistent accounts of the event. The facility's medication error report identified the root cause as the medication cup being left on the cart. The incident was not immediately communicated to the facility's CEO, and the resident's family was notified only after the resident was found unresponsive.