Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including diabetes with chronic kidney disease, acute respiratory failure, and moderate cognitive impairment, was administered another resident's medications. The medications given included amiodarone, bumetanide, carvedilol, clozapine, divalproex, Jardiance, and lamotrigine. The facility's policy required staff to verify the resident's identity using a photo in the electronic medical record and by asking the resident's name, as well as to follow the six rights of medication administration. The error took place when an LPN, preparing to administer medications, mistook one resident for another after a resident approached the medication cart and asked for medication. The LPN engaged in conversation, took vital signs, and administered the medications intended for a different resident without properly verifying the resident's identity. The mistake was discovered when the actual intended recipient was later brought to the unit, prompting the LPN to realize the error after checking the medication drawer and confirming the wrong resident had received the medications. Following the administration of the incorrect medications, the affected resident became lethargic, was unable to respond verbally, and exhibited slow, shallow respirations with drooling. Vital signs were taken, and emergency services were called. The resident was transported to the hospital for further care. The incident was documented in the resident's progress notes, and the LPN involved provided a written statement describing the sequence of events that led to the error.