Significant Medication Error Due to Incorrect Resident Identification
Penalty
Summary
A certified medication aide (CMA) administered a set of medications intended for one resident to a different resident, resulting in a significant medication error. The error occurred when the CMA prepared medications for a resident who typically ate breakfast in her room but, on this occasion, was found in the dining room. The CMA mistakenly identified another resident as the intended recipient and administered the wrong medications. The error was recognized by the CMA upon reviewing the medication label and was immediately reported to the charge nurse on duty. The resident who received the incorrect medications had a medical history including a left pelvic fracture, paroxysmal atrial fibrillation, type 2 diabetes mellitus with chronic kidney disease, and carotid artery stenosis. After receiving the wrong medications, the resident initially denied symptoms but later experienced nausea, vomiting, and lightheadedness, leading to a request for evaluation at the local emergency department. The incident was documented, and the resident was monitored as per provider instructions. Interviews and record reviews revealed that other staff members who administered medications were not formally educated or re-educated about the incident or the medication administration policy following the error. Several staff members were unaware of the specifics of the incident or could not recall the six rights of medication administration. There was no evidence of formal staff-wide education, monitoring, or auditing of medication administration practices after the event, and the facility's policies did not specify requirements for staff education or follow-up monitoring after such incidents.