Significant Medication Error Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
A significant medication error occurred when an LPN administered intravenous (IV) antibiotics to the wrong residents. Specifically, one resident with a physician's order for Meropenem for a heel wound infection received Zosyn, while another resident with an order for Zosyn for a toe infection received Meropenem. The error was discovered after the IV infusions were completed, with the medication bags clearly labeled with the respective residents' names and medications. The LPN reported issues with computer access and poor lighting at the time of administration, which contributed to the failure to follow the facility's medication administration procedures, including the required three checks and the 5 Rights of Medication Administration. The resident who received the incorrect medication (Zosyn instead of Meropenem) experienced adverse effects, including vomiting, flushed face, chills, and was subsequently transferred to the hospital, where they were admitted with a diagnosis of drug reaction, fever, and tachycardia. The other resident who received Meropenem instead of Zosyn was closely monitored and did not display any adverse effects. Both residents had complex medical histories, including osteomyelitis and other chronic conditions, and required assistance with activities of daily living. The error was immediately reported to the medical doctor, and the residents were monitored following the incident. The investigation revealed that the LPN did not adhere to established medication administration protocols, despite having completed competency checks and education on these procedures. The LPN prepared both residents' IV antibiotics at the nurse station desk due to computer issues and administered them without proper verification. The error was identified when the Clinical Manager responded to IV pump alarms and noticed the medications had been switched. Statements from staff confirmed that the LPN did not follow the required safety checks, leading to the administration of the wrong medications.
Removal Plan
- LPN #1 was found to administer the incorrect IV antibiotic medications to Resident #1 and Resident #2; MD was notified and both residents were closely monitored
- Nurse medication administration observation checklist was completed and LPN #1 demonstrated competency after medication error was found
- LPN #1 was suspended and terminated
- A 100% audit of all current residents that have physician order of IV antibiotics were reviewed by the assistant director of nursing (ADON) to validate the correct IV antibiotics orders and that IV medications were in the medication room
- Medication administration education began and IV competencies began for all nurses - all nursing staff must complete education and competencies before their next scheduled shift
- All newly hired nurses will be educated on proper medication administration including return demonstration during orientation
- A new process was created requiring two nurses to verify the correct IV medication before administering to residents
- Random audits were being conducted monitoring nurses who were administering IVs