Significant Medication Error Leading to ICU Admission After Wrong-Resident Administration
Penalty
Summary
A resident with intact cognition and multiple diagnoses including chronic kidney disease, peripheral vascular disease, hypertension, and diabetes was involved in a significant medication error shortly after admission. The resident reported that she was given medications that belonged to her roommate and stated she told the staff member the medications were not hers, but the staff member insisted they were. She took the medications, believing the physician might have changed her regimen upon admission, and subsequently blacked out and fell from her scooter. The clinical record included a progress note documenting that the resident fell as a result of a medication error and that her blood pressure was low, prompting contact with the nurse practitioner and transfer to the hospital. Hospital records showed the resident was admitted to the ICU for accidental ingestion of a muscle relaxant, an anticonvulsant, an anti-anxiety medication, and a blood pressure medication, and was followed for persistent bradycardia and hypotension requiring medications, oxygen, and intermittent vasopressor support. Facility staff interviews revealed that a CMA who was training another CMA removed medications for three residents, placed them in cups on top of the medication cart, and handed the keys to the trainee before going on break. The trainee then administered the medications, believing she was giving them to the intended resident, but was unaware there was a new resident in the same room and did not use the six rights of medication administration. The trainee acknowledged that the new resident did not yet have a photo in the EHR and admitted she did not follow the required resident identification and medication verification process. The facility’s policy required use of the resident photo in the MAR and adherence to the six rights of medication administration, which were not followed in this incident.
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