Significant Medication Error Due to Incorrect Morphine Administration
Penalty
Summary
A significant medication error occurred when a resident was administered an incorrect dosage of morphine sulfate. The physician's order specified a dose of 0.25 ml of morphine concentrate to be given as needed, but the LPN on duty administered 2.5 ml, which was the lowest measurable line on the plastic medication cup used. The pharmacy did not provide a calibrated syringe with the medication, and the LPN was unable to locate one in the facility. Instead of seeking further guidance or delaying administration, the LPN used the medication cup, which was not suitable for measuring such a small dose. The error was discovered during the end-of-shift narcotic count, which revealed a discrepancy in the morphine supply. Following the administration of the incorrect dose, the resident experienced a significant change in condition, including decreased oxygen saturation, bradycardia, and respiratory depression. Progress notes documented that the resident became difficult to arouse and eventually unresponsive, with vital signs indicating respiratory compromise. Emergency services were contacted, and Narcan was administered, resulting in improvement of the resident's vital signs. The resident had a history of chronic kidney disease, which can affect morphine metabolism and increase the risk of adverse effects. Interviews with facility staff and the pharmacy consultant confirmed that morphine sulfate should only be administered using a calibrated oral syringe to ensure accurate dosing. The use of an inappropriate measuring device directly led to the overdose. The facility's policy and FDA guidance both require the use of a calibrated syringe for morphine administration, and the failure to follow these protocols resulted in a significant medication error and harm to the resident.