IDPH has cited and fined Sunset Rehabilitation and Health Care Center nursing home in Canton after a resident there had to be hospitalized in the intensive care unit after a medication error in which the the nurse gave medications to the wrong resident.
Many nursing home residents are on multiple medications. One of the basic tasks for members of the nursing staff is to give the medications to the resident as ordered by the doctor.
To safely do this, and avoid nursing home medications errors, nurses are supposed to check the 5 “rights” before giving medications to the resident: (1) is this the right resident, (2) is this the right medication, (3) is this the right dose, (4) is this the right route (pill, oral, etc.), and (5) is this the right time? Checking each of the 5 rights is a simple, but proven and effective way to avoid preventable medication errors.
The resident at issue was a known choking risk. When the nurse went to pass medications to her, the resident was in bed. To reduce the risk of aspiration, the nurse asked the aides to get the resident out of bed. The aides did so, placed the resident in her wheelchair, and brought her to the nurse’s station.
When the resident arrived at the nurse’s station, the nurse was preparing medications for other residents. There were other residents surrounding the nurse’s station asking for their medications.
Because the resident at issue was a choking risk, she would normally receive her medications in pudding. The nurse placed medications into the pudding cup and gave it to the resident. Unfortunately, when she put the medication into the pudding cup, she put medications for another resident into the pudding cup. The resident swallowed the medications before the nurse realized that she made a medication error by giving the resident the wrong medications. Among the wrong medications that the resident received were two diabetes medications and two antipsychotic medications.
To her credit, the nurse realized the medication error almost immediately and notified the resident’s doctor and the nursing home administration. The doctor instructed the nurse to do blood sugar testing on the resident and monitor for lethargy. Within a couple of hours, the resident began to demonstrate significant lethargy. The nursing staff notified the doctor of the changes in the resident’s condition and he ordered her sent to the hospital.
The resident was admitted to the hospital into the intensive care unit suffering from hypoglycemia, or low blood sugar, associated with the effects of being the other resident’s diabetes medications. She also experienced a couple of seizures. The resident further reported to the state surveyor that she was feeling the ill effects of the medication error even after being discharged back to the nursing home.
This was a highly preventable medication error. Giving one resident medications that were intended for another resident is the kind of medication error which should never occur – that is one of the basic “5 rights” that should be verified before giving medication. However, the nurse got distracted, and a serious and highly avoidable medication error occurred.
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