Significant Medication Error: Overdose of Methadone Administered
Penalty
Summary
A registered nurse (RN) administered a significant medication error to a resident who had been admitted with acute heart failure, dementia, and failure to thrive. The resident had physician orders for methadone 5 mg orally twice daily and hydromorphone as needed for pain. On one occasion, the RN, while distracted and rushing due to the needs of another resident, mistakenly administered five tablets of methadone 5 mg (totaling 25 mg) instead of the prescribed single 5 mg tablet. The error was not immediately recognized and was only discovered the following day during a narcotics count. Following the administration of the incorrect methadone dose, the resident received additional doses of hydromorphone both before and after the error. The resident subsequently experienced vomiting and was observed to be over-sedated. Facility documentation and interviews confirmed the medication error, the circumstances leading to it, and the resident's adverse reaction. The facility's policy required nursing staff to adhere to the seven rights of medication administration, including the right amount and right time, which was not followed in this instance.