Medication Administration Error: Incorrect Morphine Dosage Given
Penalty
Summary
The facility failed to ensure that a medication was administered according to the physician's order for one resident. The resident, who had diagnoses including chronic pain due to trauma, anxiety disorder, depression, and diabetes mellitus, was prescribed one milliliter (ml) of Morphine Sulfate Oral Suspension at a strength of 20 mg per five ml (equivalent to four mg per dose) every two hours as needed for breakthrough pain. However, review of the Controlled Drug Receipt Record/Disposition Forms and Medication Administration Records revealed that the Morphine Sulfate supplied and administered was at a strength of 100 mg per five ml (equivalent to 20 mg per one ml), and one ml of this higher-strength medication was administered at each dose, resulting in the resident receiving 20 mg per dose instead of the prescribed four mg. Multiple nurses documented the removal and administration of the higher-strength Morphine Sulfate over 300 times, and this discrepancy was confirmed through observation and interview with an LPN. The LPN acknowledged that the amount administered did not match the physician's order. Despite this, the resident did not experience any episodes of respiratory depression, oversedation, or other adverse side effects during the period in question. Facility policy required medications to be administered in accordance with prescriber orders and for staff to verify the right medication and dosage before administration, which was not followed in this case.