A resident was given the wrong IV medication by a nurse manager—Zosyn instead of Meropenem. The error was discovered by a family member when the medication was finished infusing. The medical director was called and advised the staff to observe the resident. The concern was for a potential allergic reaction to the medication given in error. The resident was assessed and then given Benadryl. She was observed for 30 minutes and then the correct medication was provided. The medical director visited the resident and the resident had no complaints.
The DON and the administrator talked with the nurse manager who was very upset. She realized that she had made a mistake and did not follow nursing protocol. She requested a day off to give herself time to gather her thoughts. The conversation was documented. The nurse received a review regarding the 5 Rights of Medication Administration: the right patient, the right drug, the right dose, the right route and the right time. The entire staff had just completed this education. Staff continued for several days to observe the resident and to document on every shift.
The nurse who made the medication error completed a med pass competency evaluation and was given a documented verbal warning. All new hires are being required to have a med pass competency evaluation along with education on the 5 Rights of Medication Administration. All staff have had their files checked for previous competency evaluations. No chart audit was needed.
