Significant Medication Error: Multiple Doses of Ambien Administered Instead of Pain Medication
Penalty
Summary
A resident with multiple medical conditions, including rib fractures, severe malnutrition, cognitive impairment, and chronic pain, was admitted to the facility with several medication orders, including hydrocodone-acetaminophen for severe pain and zolpidem (Ambien) for insomnia. The resident's care plans included specific interventions for pain management and monitoring for adverse effects related to hypnotic medications. The facility's medication administration policy required staff to verify medications three times before administration and to compare the medication label with the Medication Administration Record (MAR). On the evening and early morning hours in question, the resident received the scheduled dose of Ambien at bedtime. Subsequently, when the resident requested pain medication, an LPN administered Ambien instead of the ordered hydrocodone-acetaminophen on two separate occasions, resulting in the resident receiving three doses of Ambien within a ten-hour period. Documentation on the MAR and in progress notes indicated that the LPN signed out hydrocodone-acetaminophen but actually administered Ambien. The resident continued to complain of severe pain throughout the night, and the error was not identified until the following shift. As a result of receiving excessive doses of Ambien and not receiving the prescribed pain medication, the resident experienced altered mental status, agitation, and uncontrolled pain, leading to a transfer to the hospital for evaluation. Hospital records indicated the resident presented with rib pain, altered mental status, and hallucinations, with the likely cause identified as the administration of three doses of Ambien. The LPN involved later acknowledged being fatigued and unfamiliar with the new resident, which contributed to the medication errors.