Medication Administration Error: Morphine Overdose Due to Transcription Mistake
Penalty
Summary
A medication administration error occurred involving a resident with diagnoses including anemia, heart failure, diabetes mellitus, and seizure disorder, who was receiving hospice care for a terminal prognosis. The resident's physician order specified morphine sulfate concentrate 20 mg/ml, to be given at 0.75 ml every hour as needed for pain or dyspnea. However, a hospice nurse transcribed a new order incorrectly, changing the dose from 0.75 ml to 7.5 ml, which is ten times the intended amount. This transcription error was not identified by the facility nurse, who subsequently administered the excessive dose using multiple syringes. Following the administration of the incorrect morphine dose, the resident exhibited symptoms requiring the use of Narcan (naloxone) to reverse opioid effects. Documentation and interviews revealed inconsistencies in the recording of Narcan administration times and the number of doses given. The error was discovered when a new bottle of morphine arrived from the pharmacy with the correct dosage label, prompting staff to realize the discrepancy and notify appropriate personnel. The facility's medication administration record and staff interviews confirmed that the error was due to the incorrect transcription and lack of verification before administration. Staff interviews indicated that there was no double-checking of hospice orders as is done with new admissions, and the nurse who administered the medication did not question the unusually large volume required for the dose. The director of nursing acknowledged the transcription error but initially did not consider it a facility error, attributing it to the hospice nurse. The facility policy requires medication errors to be reported promptly and defines significant errors as those jeopardizing resident health and safety, which was the case in this incident.