Patient Safety Alert
Resultant harm to the patient
- Event 1: A patient was transferred to the ICU for hypoventilation after receiving multiple doses of a sustained release narcotic, which was inaccurately filled and administered to the patient.
- Event 2: A patient received a naloxone infusion for five hours after extended release Morphine was crushed and administered via a J-tube.
Actions to mitigate risk at your hospital
- Assess dispensing and verification procedures for high-risk medications such as sustained/extended release narcotics (e.g., frequency ordered, locations where administered, services who order)
- Consider identifying extended release medications through unique labeling
- Consider implementing a “red zone” to decrease distractions during medication preparation
- Use an automated dispensing cabinet for high-risk medications (e.g. look alike/sound alike)
- Distribute ISMP's list of oral dosage forms that should not be crushed to clinical staff
- Medical and Clinical Leaders
- Quality Improvement
- Patient Safety
- Risk Management
- Clinical Educators
- Cause Analysis Staff
- Organizational Leaders
- Event 1: The patient’s order was for an IR (immediate release) form of oral Morphine Sulfate. The pharmacy inadvertently filled the prescription with an ER (extended release) tablet. The delivery bag label indicated immediate release. However, the medication tablet inside the bag was ER instead of IR.
- Event 2: The patient was ordered to be NPO for an upcoming test. The patient had a J-tube. The patient’s medications included an oral extended release Morphine Sulfate. The nurse did not recognize that the prescribed medication was extended release, crushed the tablet and administered via a J-tube.
Key contributing factors
- Process: Inadequate checks and review of medications; omitted action - not checking “right medication”
- Workflow: Failure to validate/verify, distraction
- Policy and Protocol: Failure to follow Medication Administration and Enteral medication administration policy
Contact: Kate Conrad, (913) 981-4118 or Barbara Weis, (913) 981-4117.