Significant Morphine Dosing Error for Hospice Resident
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a medication aide administered an incorrect dose of morphine. The resident had a history of multiple strokes, was severely cognitively impaired, dependent on staff for all ADLs, and was receiving hospice and end-of-life care. A physician’s order directed morphine 20 mg/ml, 0.25 ml every 4 hours as needed for pain and shortness of breath. On the date of the incident, after a family member reported the resident appeared to be in pain or discomfort, the medication aide assessed the resident as restless, retrieved the morphine from the medication cart, and reported that she checked the bottle label and directions before pouring and administering 2.5 ml instead of the ordered 0.25 ml. She documented administration of 2.5 ml on the narcotic record, leaving 27.50 ml remaining in the 30 ml bottle. The error was not recognized at the time of administration and was not detected during routine narcotic shift-change counts, which involved two staff members reviewing the beginning amount, amount given, and amount remaining. The discrepancy was only identified two days later when a nurse prepared to administer a subsequent dose and compared the ordered 0.25 ml to the previously documented 2.5 ml dose. Interviews with the hospice nurse, DON, and nurse practitioner indicated that following the incorrect dose, the resident was repeatedly observed resting comfortably, with stable or acceptable clinical observations such as warm, dry skin, normal chest rise, and no noted discoloration of lips or fingertips. The nurse practitioner and hospice nurse both described the resident as gradually declining over the prior week in the context of end-of-life care, and the nurse practitioner stated that although the resident received a much higher dose of morphine than ordered, it did not affect his outcome and he later passed away peacefully.
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