Significant Medication Error Involving Misadministration of Ear Drops to Eye
Penalty
Summary
The facility failed to prevent a significant medication error when staff administered ciprofloxacin ear drops into a resident’s right eye instead of the ordered route to the right ear. Facility policy on medication administration required staff to read medication labels three times and to cross-check all new or questionable medication orders against the physician’s order, the eMAR, and the drug label, and the CMT training manual emphasized the five rights of medication administration (right resident, medication, dose, route, and time). The resident, who had a diagnosis of otitis media and a hospital discharge order for ciprofloxacin 0.3% solution, two drops to the right ear four times daily, had corresponding physician orders and MAR entries specifying ciprofloxacin 0.2% ear drops to the right ear four times daily. There were no physician orders for eye drops. On the date of the incident, RN A, working in the role of a CMT, administered the ciprofloxacin ear drops into the resident’s right eye instead of the right ear after misreading the label as indicating eye rather than ear. The resident reported immediate pain and blurred vision after the administration and notified another nurse, and subsequent documentation noted blurred vision without redness or discharge. Reference material from Drugs.com cited in the report stated that ear drops and eye drops are not interchangeable and that ear drops placed in the eye can cause immediate burning, itching, redness, blurred vision, and swelling. Interviews with nursing staff revealed that some LPNs could not recall recent in-service training on the rights of medication administration or had not received training on eye or ear drop administration, and the Administrator stated she did not believe all staff needed in-servicing on medication administration because RN A acknowledged making the mistake.
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