Significant Medication Error: Extended-Release Morphine Crushed and Administered
Penalty
Summary
A licensed nurse crushed and administered morphine sulfate extended-release tablets to a resident with cancer, despite clear instructions from the manufacturer and pharmacy that the medication should be swallowed whole and not crushed. The resident was not able to make her own decisions, as indicated by a Brief Interview for Mental Status score of 8 out of 15. The nurse documented in the nurse's note that the morphine was given crushed in yogurt. The medication administration record confirmed that the nurse administered the medication as prescribed, but in a crushed form. Facility policies and pharmacy guidelines specifically stated that medications should only be crushed when appropriate and safe, and that extended-release tablets labeled as 'do not crush' must not be altered. The medication packaging also included a warning label stating 'Swallow Whole. Do Not Chew Or Crush.' Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that morphine sulfate extended-release should not be crushed and that this constituted a medication error.