A nurse at a Minnesota nursing home transcribed a resident’s medication order on a different person’s chart. Her colleague also failed to properly match the drug with the patient’s medication administration record (MAR).

How It Happened

According to the Minnesota Department of Health’s official investigative report, two nurses neglected to follow established facility procedures for handling the drug in question. Specifically, the nurse who signed off on the medication put the order on the wrong resident’s MAR. The second nurse failed to double-check the order against that wrong patient’s chart. Additionally, the entire

care team failed to catch the errors for nine days.

The Result

The resident was taking the drug, an anticoagulant, because they had a history of developing blood clots. During the nine-day window, the resident developed clots in their brain that eventually caused a large—and fatal—ischemic stroke.

1. What do you believe contributed to the nurse’s error?

2. As a nurse, what would you do to help prevent the error from occurring?. Get  Nursing Assignments  Help Today