Significant Medication Error Due to Incorrect Morphine Sulfate Dose
Penalty
Summary
A significant medication error occurred when a resident with a history of a displaced spiral fracture of the left tibia and chronic pain was administered an incorrect dose of Morphine Sulfate Oral Solution. The physician's order specified Morphine Sulfate 10mg/5ml, with a dose of 2.5 ml by mouth every 4 hours as needed for moderate pain. However, the resident was given a 50mg dose instead of the ordered 5mg dose, due to the administration of Morphine Sulfate 100mg/5ml solution rather than the prescribed concentration. This error was identified after the medication was administered, and the resident was closely monitored, with no apparent adverse effects noted at the time of evaluation. The error was facilitated by a breakdown in medication storage and verification procedures. The Morphine Sulfate 100mg/5ml was not stored in the Omnicell automated dispensing cabinet due to a barcode issue, and was instead kept in a locked cabinet in the nursing supervisor's office. On the day of the incident, the RN supervisor removed the medication from the locked cabinet and provided it to an LPN without verifying the medication order or the concentration of the medication. The LPN, in turn, did not check the label on the medication against the physician's order before administration, assuming it was correct. Facility policy required a three-way check to compare the medication to the medication administration record and the prescription label, as well as verification of the correct medication and dose prior to administration. Both the RN supervisor and the LPN failed to follow these procedures, resulting in the administration of the incorrect dose. The incident was documented as a medication administration error, as the resident received a different dosage than specified by the original order.