Significant Medication Error Resulting in Opiate Overdose
Penalty
Summary
A resident with multiple diagnoses, including renal insufficiency, diabetes mellitus, and chronic pain syndrome, was prescribed a fentanyl transdermal patch to be applied every three days and morphine sulfate ER twice daily for pain management. On review of the medication administration record, it was found that the resident received both medications as ordered. However, on one occasion, a registered nurse applied a new fentanyl patch without removing the old one, as she did not see the previous patch and failed to document its removal. This resulted in the resident having two fentanyl patches applied simultaneously. Following this medication error, the resident experienced a change in level of consciousness and required hospitalization. Hospital discharge documentation confirmed the resident was admitted to the intensive care unit due to an accidental opiate overdose and was treated with intravenous Narcan. The facility's policy on controlled substances requires compliance with all laws and regulations regarding handling, storage, disposal, and documentation of controlled medications, but this was not followed in this instance.