Failure to Prevent Significant Medication Error Due to Allergy
Penalty
Summary
A resident with diagnoses including dementia, aphasia, and malnutrition, and a documented allergy to Tylenol, was administered Tylenol by an LPN without a physician's order and despite the allergy being noted in the clinical record. The LPN did not review the resident's chart prior to administering the medication. The error was discovered when the nurse began charting the administration, at which point it was realized that Tylenol was both not ordered and listed as an allergy for the resident. Facility policy requires that medications be administered as prescribed, following the five rights of medication administration, and that staff verify these rights at multiple points during the process. In this incident, the LPN failed to adhere to these protocols, resulting in a significant medication error. The event was confirmed by both the LPN involved and the Chief Nursing Officer during interviews.