Incorrect Morphine Route Transcription for NPO Hospice Resident
Penalty
Summary
Facility staff failed to ensure that a resident was free from a significant medication error when a morphine order was entered and maintained with an incorrect route of administration. The resident was admitted with multiple diagnoses including seizure disorder, adrenal insufficiency, bowel dysfunction, DM, intellectual delay, Ogilvie syndrome, gastrostomy status, dependence on supplemental oxygen, aspiration pneumonia, and was on hospice/comfort care. The resident had a malfunctioning G-tube and was ordered NPO with no GT use due to prior massive abdominal distention and stomach collapse. Despite this, a physician’s order for morphine sulfate concentrate was written and transcribed as an oral medication, even though the resident could not receive anything by mouth. On admission, the nurse assigned to the resident reviewed the hospital discharge medication list with the physician and then transcribed the approved orders into the electronic health record. The morphine sulfate order was entered as “by mouth” on the MAR, and this incorrect route was not corrected by the admitting nurse, the unit manager performing the 24-hour chart check, the dispensing pharmacist, the consultant pharmacist, or the Medical Director. The facility’s Medication Transcription policy required that all medication orders be transcribed accurately and match the prescriber’s order, and that medications from external sources be reviewed for accurate dosage and approved by the physician before administration. However, there was no documentation showing that any of the involved clinicians identified or corrected the oral route for morphine in light of the resident’s NPO status and non-functioning G-tube. The March MAR showed that the morphine sulfate oral solution was never administered to the resident during the stay, but the incorrect oral route remained on the MAR throughout. The NCC MERP definition of medication error, cited in the report, includes preventable events at any stage of the medication management process, including prescribing, transcribing, and dispensing, and notes that the potential for harm exists even if an error is caught before administration. During interview, the DON confirmed the admission and transcription process and could not provide any documentation from the dispensing pharmacy indicating the morphine order was incorrect. The LPN who completed the 24-hour chart check acknowledged that she did not consider the route for morphine during her review, stated that the medication could have been given by another route, and agreed that the situation was a near miss and an error.
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