Significant Medication Error Resulting in Resident Death
Penalty
Summary
A significant medication error occurred when a resident admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, was administered four incorrect doses of morphine sulfate, totaling 80 milligrams over a 12-hour period. The original hospice order specified morphine 5 mg by mouth every four hours as needed, but during the admission process, a transcription error resulted in the order being entered as 20 mg per dose. This error was not identified during the triple check process or by subsequent staff administering the medication. Multiple staff members, including registered nurses and licensed practical nurses, were involved in the medication administration and order entry process. The error was not questioned until after the fourth dose had been given, at which point a nurse reviewed the medication and brought the issue to the attention of supervisory staff. Interviews revealed that staff assumed the order was correct, particularly because the resident was on hospice care, and did not verify the appropriateness of the dose or question the high dosage of morphine being administered. The resident, who had not previously received morphine at home, became unresponsive and died following the administration of the incorrect doses. Family members raised concerns about the resident's condition and the potential use of Narcan, but were advised by facility staff and a physician that Narcan was not appropriate or effective at that time. The facility's policies on medication administration and error reporting were not followed, and the error was only identified after significant harm had occurred.
Removal Plan
- Narcotic orders were reviewed for ongoing appropriateness and safety by Medical Director #1.
- Narcotic orders were reviewed for ongoing appropriateness and safety. Immediate education was provided to Physician #1 and Licensed Practical Nurse #1, and the order was amended by Chief Nursing Officer #1 and Medical Director #1.
- All active medication orders were reviewed by the consultant pharmacists and medical director for ongoing appropriateness and safety.
- Administrator #1 worked with electronic ordering system creators to enable a feature to run reports that reflected ordering errors for closer daily monitoring.
- All on-call physicians and nurse practitioners were in serviced by the Medical Director #1 regarding high-risk medications and review of electronic ordering for safe dosing.
- The remaining physicians and nurse practitioners were inserviced.
- ‘Transcription of Orders' policy was developed to include information regarding medication reconciliation as well as the triple check process.
- Compared transcribed orders with original provider order for accuracy. Checks were completed and documented in the paper chart for the next two consecutive shifts.
- All nursing including agency staff will be educated by nursing educator/designee prior to start of shift on the updated Medication Error Reporting policy, which includes directions on provider and family notification as well as resident monitoring and documentation requirements.
- Education Sign-In Sheets titled Transcription- Triple Check- Medication Reconsolidation, Transfer report - hand off sheet, Neglect related to Resident Monitoring - Education sign-in sheets documented in house nurses and agency nurses educated. Agency nurses left to educate if they return to the facility.
- Chief Nursing Officer #1 stated that the medication nurse was educated regarding an end date needed for the order and printing orders to place in the chart to begin the triple check process.
- Medical Director #1, and/or Administrator #1 and/or Chief Nursing Officer #1 would check orders from the previous day.
- Nurse Managers were responsible for completing audits on triple check and would bring audit results to Quality Assurance monthly meetings.
- Surveyors verified the facility conducted a daily 24-hour look back on all new medication orders by Director of Nursing #1 or designee.
- Interviews with all parties responsible for these barrier checks showed they were aware of their required responsibilities.