Medication Error: Incorrect Opioid Administered from E-Kit
Penalty
Summary
A medication error occurred when a nurse administered Percocet (oxycodone/acetaminophen) instead of the prescribed Norco (hydrocodone/acetaminophen) to a resident who had been admitted with a right femur fracture and was experiencing severe pain. The physician's order specified Norco 10/325 mg to be given every four hours as needed, but on the specified date, two doses of Percocet 10/325 mg were taken from the emergency kit (E-kit) and given to the resident. This error was acknowledged by the Director of Nursing (DON) and was documented in both an incident report from the pharmacist and a facility post-event review, which confirmed that the wrong medication was removed and administered from the E-kit. Interviews with facility staff, including the DON and the Pharmacist Consultant, confirmed that the nurse failed to follow the facility's medication administration policy, which requires checking the medication label three times to ensure the right resident, medication, dosage, time, and route. The incident exposed the resident to the risk of adverse effects associated with Percocet, as noted by the DON and Pharmacist Consultant. The facility's records and interviews consistently indicated that the error was due to the nurse mistakenly selecting the incorrect medication from the E-kit.