Significant Medication Error Due to LPN Distraction
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered the morning medications intended for one resident to another resident. The LPN became distracted during the medication pass by another resident and a family member, which led to the error. The medications given in error included gabapentin, oxycontin ER, bumetanide, Entresto, and Flomax, all of which were prescribed for the other resident. The facility's policy required adherence to the seven rights of medication administration, including verifying the right resident, which was not followed in this instance. The resident who received the incorrect medications had a medical history of cerebrovascular disease, vascular dementia, and hypertension, and was cognitively intact at the time of the incident. Following the administration of the wrong medications, the resident exhibited low blood pressure and lethargy. The error was identified and reported by the LPN immediately after it occurred. The Director of Nursing confirmed that the resident received another resident's medications, including cardiac medications, and considered the incident a significant medication error.