Medication Error Due to Improper Administration Practices
Penalty
Summary
A medication error occurred when a Licensed Practical Nurse (LPN) administered the wrong medication to a resident with diagnoses including schizophrenia, hypertension, and a history of falls. The LPN had two different residents' medications in cups at the top of the medication cart. While attempting to administer medication in the hallway, the LPN knocked over the cups, replaced the medications, and then gave the resident the medications. After administration, the LPN realized that the resident had received another resident's narcotic medication, Tramadol, which was not ordered for him. Review of the resident's medical record confirmed there was no physician's order for Tramadol for this resident. The facility's policy required staff to verify resident identity and administer medications according to orders, which was not followed in this instance. The Director of Nursing confirmed the medication error and stated that staff are not permitted to pre-pour multiple residents' medications at one time.