Medication Error Due to Failure in Resident Identification and Timely Notification
Penalty
Summary
A medication error occurred when a licensed nurse administered a set of prescribed medications intended for one resident to the incorrect resident. The nurse prepared the medications for the intended resident at the doorway of a shared room but then approached the wrong resident and failed to verify the resident's identity using the identification bracelet, relying instead on a verbal confirmation and a photo in the medical record. The nurse did not inform the resident of the medications being administered. After the medications were given, the resident questioned the absence of a specific medication, prompting the nurse to realize the error. At this point, the nurse could not locate a supervisor and instead informed another nurse, but did not fully disclose the extent of the error. The resident who received the incorrect medications had a history of cardiac conditions, including hypertension, heart failure, and atrial fibrillation, and was prescribed different medications than those administered. Following the error, the resident experienced a significant drop in blood pressure and required immediate interventions, including fluids, medication for hypotension, and positioning. The resident was subsequently transferred to the emergency department for further evaluation and treatment, where additional fluids were administered and poison control was consulted. The resident returned to the facility later that day in stable condition. The facility's policies required verification of resident identity using multiple identifiers and immediate notification of a registered nurse and provider in the event of a medication error. However, the nurse failed to follow these protocols, both in verifying the resident's identity and in promptly notifying the appropriate clinical staff and provider about the error. The incident was not fully reported until after the nurse had continued the medication pass, and the full extent of the error was only discovered later by supervisory staff.