Medication Error Due to Failure to Follow Identification Protocols
Penalty
Summary
A deficiency occurred when a registered nurse administered the wrong medication to a resident. The nurse prepared and gave 4 units of Novolog and 16 units of Lantus insulin to a resident who was not the intended recipient; the insulin was meant for the resident's roommate. The resident who received the medication in error had diagnoses including Type 2 Diabetes Mellitus, Respiratory Failure, Pneumonia, and Toxic Effect of Tobacco Cigarettes, and was cognitively intact according to a recent assessment. The nurse became distracted during the medication pass, failed to verify the resident's identity, and did not follow the facility's medication administration policy, which requires checking the resident's identification band, confirming the resident's name, and verifying the face sheet picture prior to administration. The nurse acknowledged not following the 5 Rights of Medication Administration and admitted to rushing and not properly checking the resident before giving the medication. The facility's policy, last revised in April 2019, specifies that medications must be administered safely and as prescribed, with verification of the resident's identity and medication details before administration. The incident was identified during interviews and record reviews, and it was confirmed that the nurse did not adhere to established protocols for medication administration, resulting in a significant medication error.