A mix-up of residents at a California nursing home upset a woman’s family after they were told she was dead, only to find she’d been confused with another resident. A nurse at the facility told the family of the 83-year-old resident that she had died. However, according to the woman’s son-in-law, it was a different resident who had died.
“They made a mistake. I looked at the deceased person; it’s not my mom, and my mom is sitting in the bed close to the deceased person. … I was furious, when I got there, I was very upset,” the son-in-law said.
A nurse told the son-in-law that the mix-up also meant the two residents had been given each other’s medications for several days.
A statement from the facility admitted the nurse made a mistake. “It’s unfortunate human error. It was an isolated incident, and the facility obviously feels very badly for the family,” the statement said. “These are electronic medical records. … What happened is, the nurse pulled the chart for the wrong [resident].”
The woman’s family plans to pursue legal action, and have moved her to another facility. The Los Angeles County Department of Public Health is investigating.
Compliance Perspective
Issue
Medication administration is an important and complex skill which tests the nurse’s analytical and critical thinking, professional judgement, and base of knowledge. Medication administration is often the focus of litigation for nurses who have a critical role in medication error prevention and resident observation. The nurse is the last person to review the order and verify dispensing of the medication. Nurses have long been taught the “5 Rights” of medication administration in an effort to decrease medication errors. The “Right” resident, drug, route, time, and dose are familiar to all nurses. Later, two additional rights were introduced which included the right documentation and the right reason/indication. More recently, the nine rights of medication administration have been proposed which also include the right form and the right response. Focusing on identifying the right resident for all care needs and then following these steps will significantly reduce the likelihood of a clinical breakdown that results in medication errors and potential harm to a resident.
Discussion Points
- Review policies and procedures regarding protocols to follow for identifying residents and for ensuring that medications are accurately administered.
- Train staff in the protocols for correctly identifying each resident, for ensuring accurate administration of medications, and for reporting medication errors, including how and to whom to report.
- Periodically audit medication administration, ensuring that annual competencies are completed for each nurse. Observe provision of resident care and also ensure competencies of direct caregivers are conducted annually and as needed.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
