Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A medication error occurred when a licensed nurse administered a full set of prescribed medications intended for one resident to the incorrect resident, who was the roommate. The nurse prepared the medications at the doorway of the shared room and, upon entering, asked the resident if she was the intended recipient. The resident affirmed, but the nurse failed to verify the resident's identity using the identification bracelet and relied solely on a photograph in the medical record, which she mistakenly believed matched the intended resident. The nurse did not inform the resident of the medications being administered and only realized the error when the resident inquired about a medication not included in the cup. 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. After ingesting the medications, the resident experienced a significant drop in blood pressure and required immediate clinical intervention, including fluids, repositioning, and close monitoring. The error was not immediately reported to supervisory staff, and the nurse continued with the medication pass for other residents before the full extent of the error was discovered. Interviews and documentation revealed that the nurse did not follow facility policy, which required verification of resident identity using at least two identifiers, such as the name band and photograph, prior to medication administration. The nurse also failed to communicate the full scope of the error to supervisory staff promptly, resulting in a delay in appropriate response. The facility's policies clearly outlined the steps for medication administration and resident identification, which were not adhered to in this incident.