Medication Error Due to Improper Resident Identification
Penalty
Summary
Facility staff failed to ensure residents remained free of significant medication errors when a Certified Medication Technician (CMT) administered another resident's Novolog insulin to a resident who did not have a physician's order for insulin. The error occurred because the two residents had similar first names, were admitted around the same time, and were located across the hall from each other. The CMT, who was unfamiliar with the residents, did not properly verify the resident's last name and date of birth prior to administering the medication, relying only on the resident's verbal confirmation of their first name. The facility's policy required staff to identify residents before administering medication and to never administer medications supplied for one resident to another. The resident who received the incorrect medication was cognitively intact and had a diagnosis of diabetes managed with metformin, not insulin. After receiving 24 units of Novolog insulin, the resident's blood glucose was monitored closely, and the physician was notified. The resident reported feeling scared by the incident but did not experience any immediate adverse effects. The CMT could not recall the specific reason for the error but acknowledged not following proper identification procedures.