Failure to Use Two Identifiers Results in Medication Error
Penalty
Summary
A nurse failed to use two patient identifiers during a routine medication pass, resulting in the administration of the wrong medications to a resident. Both residents involved were seated at the same dining room table and were wearing hats, which contributed to the misidentification. The nurse did not follow the facility's policy requiring the use of at least two identifiers before administering medications, and instead relied on visual recognition, which proved insufficient in this situation. The error was discovered when the nurse returned to the dining room and noticed that the intended recipient of the medication had been moved to a different table. The resident who received the incorrect medications had multiple complex medical conditions, including Diabetes Mellitus Type II, End Stage Renal Disease, Atherosclerotic Heart Disease, and others. The medications administered were intended for another resident and included Gabapentin, GuaiFENesin ER, Norco, Magnesium oxide, Melatonin, Metoprolol, Multaq, Pravastatin, and Trazadone. The Director of Nursing confirmed the error and stated that the expectation is for staff to use two identifiers during medication administration, as outlined in facility policy.