Medication Administration Error: Resident Given Another Resident's Medications
Penalty
Summary
A resident with a history of joint replacement, cerebral infarction, pulmonary hypertension, and a documented allergy to statins was administered another resident's medications, including donepezil, buspirone, namenda, and lipitor. The error occurred when an LPN, after reviewing the electronic medical record, mistakenly pulled and administered the wrong medications during the evening medication pass. The resident's care plan indicated a risk for adverse effects from antianxiety medications, and the MAR clearly listed the statin allergy. The LPN realized the mistake after returning to the electronic record and immediately reported the incident to supervisory staff. Interviews confirmed that the resident received medications not prescribed to them, including a statin to which they were allergic. The error was discovered promptly, and the resident was assessed and monitored for adverse reactions. The incident was communicated to the resident's representative, the on-call physician, and the pharmacy. The pharmacist director was not informed until later. The resident did not report any immediate adverse effects from the medications administered in error.