Medication Labeling and Administration Error with Morphine Sulfate
Penalty
Summary
Facility staff failed to ensure that a resident's medication, Morphine Sulfate, was accurately labeled and administered according to physician orders. The resident, who had diagnoses including multiple sclerosis, epilepsy, long-term opiate use, and a history of traumatic brain injury, was severely cognitively impaired and unable to self-advocate. The physician's orders specified Morphine Sulfate Oral Solution at a concentration of 10 mg/5 ml, with various dosing instructions for administration via G-Tube and buccally. However, the pharmacy dispensed Morphine Sulfate at a concentration of 100 mg/5 ml, and the medication bottle, as well as the narcotic control sheet, were labeled with this incorrect concentration and dosing instructions that did not match the original physician order. Nursing staff administered the morphine based on the incorrect label and narcotic control sheet, resulting in the resident receiving multiple incorrect doses. The medication administration record (MAR) did not match the concentration or instructions on the medication bottle or narcotic control sheet. Nurses failed to compare the medication label to the physician's order prior to administration, as required by facility policy. This failure led to the administration of significantly higher doses of morphine than prescribed. The facility's policy required staff to verify the right medication, dosage, time, and route before administration, but this procedure was not followed. The error was discovered after the resident had already received several incorrect doses. The administrator confirmed that the pharmacy had sent a different concentration than ordered, labeled the dosage incorrectly, and that nursing staff did not verify the label against the physician's order before administering the medication.