Significant Medication Errors Due to Identification and Order Parameter Failures
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration processes. In the first case, a resident with multiple diagnoses, including diabetes and congestive heart failure, was administered another resident's medications, which included narcotics and aspirin, despite a documented allergy to aspirin. The error occurred because the resident's photo identification was not uploaded into the electronic medical record (EMR), leading the LPN to mistake the resident for someone else. The error was immediately recognized, and the resident required emergency intervention with Narcan and oxygen before being transported to the hospital for further care. In the second case, a resident with type 2 diabetes was administered insulin despite physician orders specifying to hold the medication if the finger stick glucose (FSG) was below 180 or if the resident was not eating. The resident did not eat breakfast or lunch, and the lunch FSG was 124 mg/dl, yet insulin was still administered. Shortly after, the resident exhibited symptoms of hypoglycemia, including disorientation, pallor, and diaphoresis, and required emergency glucose administration and hospital transfer. Both incidents were identified as Immediate Jeopardy situations due to the risk of serious adverse outcomes. The deficiencies were attributed to the absence of a photo ID in the EMR in the first case and failure to adhere to medication parameters in the second case. Staff interviews and documentation confirmed that the errors were promptly reported and that the residents received immediate medical attention.