Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive deficits was administered medications intended for her roommate. The error took place after the RN had already prepared the medications for the roommate and, while assisting the resident in the restroom, inadvertently gave her the wrong medications. The medications administered included morphine sulfate, quetiapine fumarate, Eliquis, clonidine, docusate sodium, carvedilol, atorvastatin, hydralazine, and gabapentin, none of which were prescribed for the resident who received them. Following the administration of the incorrect medications, the resident exhibited symptoms including feeling sick, a weak pulse, hypotension, and diaphoresis. The RN recognized the error and began monitoring the resident, who subsequently required emergency medical attention. The nurse notified the Unit Manager, who instructed her to contact the physician. The resident was transported to the emergency department, where she was treated for drug overdose and received Narcan and intravenous fluids. The facility's documentation revealed that vital signs were not recorded in the medical record as expected. Both the DON and Unit Manager confirmed that there was no documentation of the resident's vital signs during the incident, despite the expectation that such monitoring should be documented. The incident was determined to be a significant medication error and was cited under pharmacy services for substandard quality of care.
Removal Plan
- MD notified and Resident was sent to the hospital. Resident returned with no adverse effects.
- All residents were assessed by the Director of Nursing with all residents without distress. Vital signs obtained and reviewed for abnormalities, none noted. All residents assessed by Director of Staff Development.
- Roommate MAR reviewed for medication administration. Resident received medications as ordered.
- Resident's names placed outside doors and pictures placed on EMR on every resident. Identification bracelets placed on all residents.
- Inservice on Medication Administration, Medication Errors Policy & Procedures was completed.
- Director of Staff Development and/or designee to provide skills competency to each nurse before next scheduled shift.
- DON to monitor medication administrations skills competencies until compliance has been met.