Medication Error Resulting in Severe Hypotension and Hospitalization
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for another resident to a cognitively intact resident who required supervision with activities of daily living. The nurse failed to verify the resident's identity and did not check the medication labels for the correct resident, medication, dosage, time, or route of administration prior to giving the medications. This action was in direct violation of the facility's medication administration policy, which requires verification of the 'five rights' before administering any medication. The error was not identified at the time of administration or during subsequent documentation. Approximately two hours after receiving the incorrect medications, the resident developed symptoms including dizziness and lightheadedness, and questioned the nurse about the medications received. Upon review, it was discovered that the resident had been given a combination of medications including antihypertensives and other drugs, which were not prescribed for him. This led to severe hypotension, with blood pressure readings dropping to critically low levels, necessitating emergency medical intervention and hospitalization. The resident's medical history included hemiplegia, atrial fibrillation, hypertensive chronic kidney disease, hypertension, and anemia. The administration of the wrong medications resulted in harm, specifically severe hypotension and hospitalization. The incident was attributed to the nurse being distracted while preparing medications and not following established clinical standards and facility policy for safe medication administration.