Medication Administration Error Due to Incorrect Emergency Kit Stocking
Penalty
Summary
A medication administration error occurred when a registered nurse administered the wrong medication to a resident with severe cognitive impairment and multiple complex medical conditions, including diabetes mellitus with a risk for hypoglycemia. The resident experienced critically low blood sugar levels, and the nurse, responding to the hypoglycemic episode, retrieved what he believed to be Glucagon from the emergency kit. However, the syringes in the compartment labeled Glucagon actually contained Enoxaparin, an anticoagulant, due to a pharmacy error in stocking the kit. The nurse administered two doses of Enoxaparin instead of Glucagon before realizing the mistake after reviewing the packaging post-administration. The resident's blood sugar remained dangerously low despite the interventions, prompting the nurse to call emergency medical services. Upon arrival, EMTs administered intravenous dextrose, and the nurse discovered the medication error. The incident was further confirmed by the Director of Nursing, who stated that the pharmacy had incorrectly placed Enoxaparin syringes in the Glucagon compartment and vice versa. The resident was subsequently transferred to the emergency room for further observation due to persistent altered mental status.