Significant Medication Error: Incorrect Morphine Dosing and Transcription
Penalty
Summary
A significant medication error occurred when a resident with multiple complex diagnoses, including Alzheimer's disease, COPD, epilepsy, diabetes with neuropathy, paranoid schizophrenia, and pain, was administered morphine at an incorrect frequency and dosage. The resident, who was severely cognitively impaired and dependent on staff for all care, was ordered morphine sulfate 100mg/5ml, 1ml by mouth every 2 hours as needed. However, following a pain crisis, a new verbal order was received from hospice to administer 1ml every 30 minutes until the resident was comfortable, then every 2 hours. The nurse on duty misinterpreted and transcribed the order as 1ml every 3 minutes, resulting in the administration of 9 doses (180mg) over a 24-minute period. The error was not immediately identified, and the nurse continued to administer morphine according to the incorrect transcription. The nurse stated she clarified the order multiple times with the hospice RN, but still proceeded with the erroneous frequency. The hospice RN, upon arrival later in the day, discovered the error during a review of the narcotic count sheet and nurse's documentation. The hospice RN and physician were notified, and the resident's responsible party was offered Narcan or transfer to the ER, but these interventions were declined. The resident was closely monitored for changes in condition, and her respiratory status declined over the following hours. Interviews with staff revealed that the nurse who administered the morphine was not familiar with the hospice provider and believed the dosing was a new pain management protocol. Other staff present at the time expressed concern about the frequency but did not intervene. The error was ultimately reported to facility leadership and the consulting pharmacist, who confirmed the dosage was outside standard prescribing guidelines. The resident's condition deteriorated, and she passed away within hours of the overdose. The facility's policy required evaluation of new medication orders for appropriate dose, route, and frequency, but this was not followed in this instance.