Crushed Extended-Release Morphine and Double Dose of Lyrica Result in Harm
Penalty
Summary
A significant medication error occurred when a nurse crushed and administered an extended-release Morphine (MS Contin) tablet to a resident, despite clear labeling and pharmacy instructions indicating the medication should not be crushed, chewed, or split. The nurse also administered double the prescribed dose of Lyrica, giving the resident 300 mg instead of the ordered 150 mg. The nurse was not aware that the Morphine ER tablet should not be crushed and had not previously worked with the resident since the medication was ordered. The error was discovered after the resident exhibited confusion, sedation, and hallucinations, prompting further assessment by the unit manager and notification of the physician's assistant. The resident involved had a history of chronic pain syndrome, opioid dependence, low back pain, and other medical conditions. He was cognitively intact and had no communication issues according to his most recent assessment. The resident had recently returned from the hospital with new orders for MS Contin and a re-instated order for Lyrica. The medication administration record and staff interviews confirmed that the resident received his scheduled doses of both medications on the morning of the incident, but the Morphine ER was crushed and the Lyrica dose was doubled in error. The error was identified after the resident's wife questioned the administration of crushed medications and the resident's change in condition. The nurse involved admitted to crushing all of the resident's medications and was unaware of the specific instructions for the Morphine ER. The facility's medication administration policy required nurses to check a "Do Not Crush" list and follow physician orders, but the nurse failed to do so. The incident resulted in the resident requiring Narcan administration to reverse the effects of opioid overdose and an evaluation at the emergency department.