Medication Administration Error Resulting in ICU Admission
Penalty
Summary
A medication administration error occurred when a nurse gave a resident both her prescribed morning medications and, in error, administered another resident's medications as well. The nurse had completed the initial medication pass for the resident, who had severe cognitive impairment and multiple diagnoses including stroke, kidney disease, diabetes, dementia, anxiety, and depression. Shortly after, the nurse prepared medications for a different resident but mistakenly called out to the first resident, who responded by opening her mouth, and the nurse administered the second set of medications to her. The error was realized approximately five minutes later when the nurse reviewed the medication records. Following the administration of the incorrect medications, the resident became unresponsive within minutes. Staff assessed the resident, notified the on-call provider, and were instructed to monitor vital signs and provide fluids. The resident was found unresponsive to verbal and physical stimuli, prompting immediate emergency intervention, including administration of Narcan and calling 911. Emergency medical services arrived, and the resident was transported to the hospital, where she was admitted to the ICU with diagnoses of toxic encephalopathy and cardiogenic shock secondary to the medication error. The resident's medical record indicated she had no swallowing disorder and was on multiple medications, including antianxiety, antidepressant, anticoagulants, hypoglycemics, and anticonvulsants. The care plan directed staff to administer medications as ordered and monitor for side effects. The incident resulted in the resident requiring intensive medical intervention, including ICU admission, and she subsequently developed severe dysphagia. Interviews with staff and family confirmed the sequence of events and the impact of the medication error.