Medication Error: Oxycodone Administered to Wrong Resident Due to Verification Failures
Penalty
Summary
A significant medication error occurred when a resident with diagnoses including Parkinson's disease, dementia, and palliative care, who was cognitively impaired and had no opioid prescription, was administered 60 mg of oxycodone intended for another resident. The error took place during a medication pass when a nurse in training (Nurse #1) was handed the medication by another nurse (Nurse #2), who had pulled the medication for the resident's roommate. Nurse #1 mistakenly believed the medication was for the resident and administered it without proper verification. Interviews and documentation revealed that Nurse #1 stated she thought she had verified the resident's name, but Nurse #2 reported not witnessing any confirmation of identity. Nurse #2 realized the error upon entering the room and immediately reported it. Both nurses notified the Unit Manager, who then informed the Nurse Practitioner and Director of Nursing. The resident was closely monitored and received naloxone and IV fluids after becoming sleepy, but remained stable throughout the monitoring period. The investigation identified that both nurses failed to follow the facility's medication administration policy, specifically the 5 rights of medication administration and the use of two resident identifiers. Additionally, it was found that the orientation and competency validation for the nurses involved was incomplete at the time of the incident, and there was inadequate supervision during the orientation process. The pharmacy consultant was not notified of the error, and the medication administration error was not discovered until after the event had occurred.