HospitalInspections.org

Based on a review of facility policy, medical record (MR), and interview with staff (EMP), it was determined that the facility failed to follow their policy to ensure that the patient received the correct dose of Morphine ordered for one of one medical record reviewed(MR1).

Findings include:

A review of facility policy "Checking a Medication Before Administration" effective date June 25, 2014, revealed, "7. Calculate recommended dose or dose range of the medication using the CHOP formulary. Calculations should be based upon the patient's weight or baby surface area (BSA)... 8. Check that the patient's ordered dose is within the calculated dose or dose range. ... ."
A review of the facility policy "Safe and Timely Administration of Medications and Fluids" effective date February 22, 2012, revealed, "Staff and physicians are accountable to follow all policies and procedures for safe and timely medication administration. ... . After checking the six rights, if there are any concerns that are not resolved to the satisfaction of the person administering the medication, that person is expected to and has the ultimate responsibility at this stage of the medication use process to clarify any concerns regarding the order being unsafe. ... . Medication errors... are tracked and analyzed to determine their causes. Datea will be reported to the Medication Safety Committee."
A review of the facility policy "Performing a Two-Clinician Independent Check Before Administering High-Alert Medications" effective date June 25, 2014, revealed, "Right Dose 7. Calculate recommended dose or dose range of the medication using the CHOP formulary. Clinician 1 and 2 Calculations should be based upon the patient's weight or body surface area (BSA). ... . 8. Check that the patient's ordered dose is within the calculated dose or dose range"
A review on August 5, 2014, of MR1 revealed a medication order for July 9, 2014, at 6:00 PM "Morphine inj 0.15 mg Route: Intravenous Frequency: ONCE Start 07/09/14 1800 Weight used for the order 2.76 kg"

A review on August 5, 2014, of MRI revealed a medication administration record for July 9, 2014, at 6:00 PM "Given dose/rate 0.15 mg Route Intravenous Site IV Push, Action Time 07/09/14 1800, Administering User: (EMP17), Dual Signoff User: (EMP16), Comment: actual dose given 1.5 mg."

A review on August 5, 2014, of MR1 revealed a EMP12's physician note for July 9, 2014, at 6:30 PM, "I was called to the bedside after the patient was given 1.5 mg of morphine. He had decreased respirations, but was stable normal oxygen saturations. Naloxone was given with immediate improvement in his respirations. ... ."

An interview conducted on August 5, 2014, at 2:00 PM with EMP2 confirmed that dose of Morphine administered to the patient on July 9, 2014, at 6:00 PM was ten times the dose ordered. Further interview revealed that the nurses involved did not follow the facility policy for safe administration of medications and missed a hugh safety step by not checking the dose ordered.