A nurse at a Minnesota long-term care facility administered a fatal dose of morphine to a resident receiving end-of-life care, according to a report from the Minnesota Department of Health (MDH). The state investigation found the incident to be the result of neglect.
The resident, whose diagnoses included stroke, dementia, diabetes, and atrial fibrillation, had been placed on comfort care following a period of respiratory distress and unstable vital signs. Instead of transferring him to a hospital, the resident’s family opted for palliative treatment, and an order was made for 20 milligrams of morphine to be administered in 5-milligram doses hourly.
However, according to the MDH report, a nurse arriving for an overnight shift misunderstood the medication order and administered the entire 100 milligrams of liquid morphine—20 times the intended amount. The nurse did not verify the dosage with a supervisor or another staff member. The resident died a few hours later.
The employee later told investigators she believed 5 milligrams was equivalent to 5 milliliters and drew up five 1-milliliter syringes of morphine, mistakenly delivering the full amount. She acknowledged the error and said she felt terrible about the outcome.
The overdose was not immediately recognized. After another staff member questioned the dose, the nurse reviewed the medication and realized she had actually given 100 milligrams, not the 5 milligrams that had been prescribed. By the time the full extent of the error was discovered, staff told the resident’s family that it was too late for Narcan to be effective. The cause of death was listed as acute morphine toxicity.
Following its investigation, the Minnesota Department of Health concluded the nurse was responsible for neglect, citing a failure to follow professional standards, exercise sound judgment, or act in the best interest of a vulnerable adult. The nurse is no longer employed at the facility.
In a public statement, facility leadership said they fully cooperated with the state’s investigation and were taking steps to address the incident. They added that efforts were underway to improve care quality and resident safety.
Compliance Perspective
Issue
Medication administration is an important part of providing safe and effective care across healthcare settings. Errors in dosage or administration can lead to adverse outcomes, especially when high-risk medications are involved. To minimize risk, facilities should ensure that staff are familiar with medication protocols, verify orders appropriately, and follow procedures that support accuracy.
Discussion Points
- Review your medication-related policies and clinical procedures to ensure they reflect current best practices and standards of care. They should include clear protocols for dose verification, staff-to-staff communication, and medication administration. Partnering with external clinical consultants can provide additional insight, helping facilities identify overlooked risks and strengthen internal processes before issues arise.
- Medication safety training should be ongoing and tailored to the specific responsibilities of clinical staff. Emphasis should be placed on verifying orders, recognizing when to seek clarification, and understanding the risks associated with commonly misused or miscalculated medications. Med-Net Academy offers courses on Medication Error Prevention and Medication Administration for Nurses, which cover common error types, proper administration techniques, and staff responsibilities in verifying medications and dosages.
- Audit medication administration processes and overall care delivery to verify staff compliance with policies and procedures. An outside review may help identify areas for improvement and support ongoing efforts to enhance medication safety.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*