Incorrect Morphine Dose Administered Due to Order Clarity and Measurement Error
Penalty
Summary
A nurse failed to accurately measure and administer a liquid narcotic medication, resulting in a resident receiving a significantly higher dose of morphine than prescribed. The physician's order specified morphine sulfate concentrate at a strength of 20 mg/mL, with instructions to give 5 mg by mouth every two hours as needed. However, the order did not specify the corresponding milliliter amount for the 5 mg dose, requiring the nurse to calculate the correct volume. On the night in question, the nurse signed out and administered 1 mL (20 mg) of morphine instead of the prescribed 0.25 mL (5 mg), as documented on the controlled substance receipt sheet and the Medication Administration Record (MAR). The error was identified by the nurse shortly after administration, and she reported the incident to the provider. The resident, who had a complex medical history including metastatic lung cancer, heart failure, COPD, anxiety disorder, and other conditions, was being managed with comfort measures and was not morphine-naive. The nurse and nurse aide closely monitored the resident's vital signs and oxygen saturation following the administration of the incorrect dose. The resident initially remained alert and stable, but later became less responsive, prompting further assessment and intervention by the nurse practitioner, including administration of Narcan to reverse the effects of the morphine. Interviews with facility staff, including the DON, nurse manager, nurse practitioner, pharmacist, and medical director, confirmed that the error was due to the lack of clarity in the original physician order, which did not specify the volume to be administered. The error was not attributed to a lack of knowledge or intent, but rather to the need for calculation based on the medication concentration. The incident was recognized as a failure to follow professional standards of medication administration, specifically in ensuring accurate measurement and documentation of narcotic medications.