Failure to Prevent Significant Medication Error in Pain Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to pain management. The resident, who was on comfort care, was prescribed morphine for pain relief. Initially, a verbal order was given for morphine 10mg/5ml, to be administered 5ml by mouth every 3 hours. This order was later discontinued the same day, and a new order for morphine 100mg/ml, to be administered at 0.25ml every 3 hours as needed, was entered. Despite the change, both morphine solutions were delivered to the facility, and nursing staff continued to use the discontinued 10mg/5ml solution, administering 0.25ml doses from it over a period of several days. A review of narcotic count sheets confirmed that the discontinued morphine solution was used 22 times by different nurses, instead of the newly ordered concentration. The Director of Nursing acknowledged that the discontinued medication should not have been delivered and that the nursing staff should have used the correct morphine solution as per the updated order. As a result, the resident received incorrect doses of morphine for pain management, and the facility did not prevent a significant medication error.