Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident's medications to a resident with diagnoses including diabetes, hypertension, prostate cancer, and congestive heart failure. The nurse, who was not the resident's regular caregiver, entered the room where multiple residents were present. Upon calling out the resident's last name, the resident responded, and the nurse proceeded to give the medications without further verification. The medications administered included several drugs not prescribed to the resident, such as Bisacodyl, Chlorpromazine, Diltiazem, Duloxetine, Loratadine, Oxybutynin, Pantoprazole, Senna Plus, Tramadol, and Vraylar. Following the administration, the resident initially denied any immediate ill effects but was later reported by family to be pale, nauseated, and had vomited. The resident's vital signs were assessed, and after further symptoms developed, the physician was notified and ordered the resident to be transferred to the hospital. Hospital records indicated the resident was admitted for observation due to medication side effects, including near syncope, nausea, vomiting, and transient bradycardia, likely related to the medications received in error. The facility's policy required verification of resident identity using multiple methods, such as checking identification bands, reviewing photographs, and confirming with other staff if necessary. However, these procedures were not fully followed during the medication pass, leading to the error. The incident was documented in nursing progress notes and confirmed through staff statements and facility investigation records.