Significant Medication Error Due to Incorrect Admission Reconciliation
Penalty
Summary
A significant medication error occurred when a resident was admitted with a history of hypertension and COPD, requiring continuous oxygen and specific medications as outlined in her hospital discharge summary. Upon admission, the facility failed to accurately reconcile the resident's medications, resulting in the administration of multiple medications that were not prescribed to her, including two blood thinners and blood pressure medications. At the same time, the resident did not receive her prescribed breathing treatments and anti-inflammatory medications, which were essential for her COPD management. The error was traced to the use of incorrect hospital discharge paperwork, which contained another individual's medication list. This paperwork was used to transcribe and order medications for the resident, leading to the administration of the wrong medications and omission of necessary treatments. The family brought the discrepancy to the facility's attention after noticing inconsistencies in the medications being administered. Upon investigation, it was confirmed that the medication list used during admission did not match the resident's actual discharge orders. During the period following admission, the resident experienced shortness of breath and anxiety, with decreasing oxygen saturation levels, ultimately resulting in her transfer back to the hospital for evaluation and treatment of a COPD exacerbation. Interviews with facility staff revealed that the admitting nurse was responsible for reconciling medications with the physician, and the ADON was to ensure accuracy in transcription. However, these processes failed, and the error was not identified until after the resident's condition deteriorated and the family intervened.