Significant Medication Error Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
A significant medication error occurred when a licensed vocational nurse (LVN) administered a set of medications intended for one resident to another resident. The nurse prepared medications for two residents simultaneously on top of the medication cart and confused the medication cups, resulting in the wrong resident receiving multiple medications not prescribed to her, including two Schedule IV controlled substances and a dose of quetiapine (Seroquel) 32 times higher than prescribed. The nurse realized the error immediately after administration and reported it to the Director of Nursing (DON) and hospice staff. The affected resident had a medical history including epilepsy, hypotension, cardiomyopathy, and schizophrenia. Following the administration of the incorrect medications, the resident initially presented with normal vital signs but soon became lethargic, unresponsive to voice or touch, and developed hypotension. Emergency services were called, and the resident was transferred to the hospital, where she was treated in the ICU for hypothermia, hypotension, and metabolic encephalopathy. Hospital records confirmed the administration of multiple medications not prescribed to the resident, as well as a positive urine drug screen for opioids, tricyclic antidepressants, and benzodiazepines. Interviews and record reviews revealed that the LVN did not follow facility policy or the five/six rights of medication administration, which require preparing and administering medications to one resident at a time and verifying resident identity. The DON confirmed that the nurse failed to adhere to these protocols, leading to the error. The incident was self-reported by the facility due to the serious injury resulting from the medication error.