Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a registered nurse administered insulin intended for one resident to another resident. The nurse was passing early morning medications and gave the insulin to the wrong resident after the resident answered to the roommate's name and did not question the medication. The nurse failed to properly verify the resident's identity according to facility policy, which requires checking the identification band, photograph, and, if necessary, confirming with other staff. The error was discovered when the nurse realized the mistake and notified the charge nurse, physician, and the resident's family. The resident who received the incorrect medication had a blood sugar check and was given IV dextrose as ordered by the physician. The resident involved had diagnoses including high blood pressure, hyperlipidemia, and a history of falls. Staff interviews revealed that standard practice for medication administration includes verifying the resident's name, checking the medication administration record (MAR), and confirming the resident's picture. However, in this incident, these verification steps were not adequately followed, resulting in the administration of another resident's Lantus insulin. The Director of Nursing confirmed that the facility failed to ensure residents were free from significant medication errors in this case.