A Medication Error Discovered on Handover
You are the overnight resident covering a 32-bed medical ward. At 23:40 the day nurse hands over that Mr. K, 78, admitted with a COPD exacerbation, received 10 mg of morphine IV instead of the ordered 1 mg at 19:00. His weight is 58 kg, eGFR 38. He is now drowsy but rousable, RR 8, SpO2 88% on 2 L nasal prongs, BP 102/60, HR 62. The nurse who gave the dose is tearful and says, 'Please don't report me, I'll lose my job.' The ordering physician wrote 'morphine 1 mg IV' but the decimal was faint on the handwritten order. The ward pharmacist is off site until 08:00.
1. Prioritise your actions in the first 30 minutes.
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This is a clinical emergency plus a patient-safety event; handle both, in that order.
First 30 minutes (clinical):
- Attend the bedside immediately. Assess airway, breathing, circulation, consciousness (AVPU/GCS), pupils, and pain.
- Call for help and start continuous monitoring: SpO2, cardiac monitor, BP every 5 minutes.
- Airway/breathing: sit him up as able, apply oxygen to target SpO2 88-92% in COPD, and support ventilation with a bag-valve-mask if RR remains <10 with inadequate tidal volumes. Prepare naloxone.
- Naloxone: give titrated doses (e.g., 0.04-0.1 mg IV increments, repeating every 2-3 minutes) to restore adequate respiratory rate and consciousness, not full reversal. Full reversal in an opioid-tolerant patient can precipitate severe pain, agitation, and pulmonary oedema. In a partially reversed patient, monitor closely because naloxone's half-life is shorter than morphine's; repeat dosing or an infusion may be needed.
- IV access, blood gas if indicated, glucose check, and review other sedatives given (benzodiazepines, antihistamines).
- Document contemporaneously and inform the patient (if able) and family.
Then patient safety: complete an incident report, inform the nurse's supervisor and the attending physician, and preserve the original order and MAR. Reporting is mandatory and non-punitive; reassure the nurse that honest reporting protects patients and her.
2. The nurse begs you not to report her. How do you respond, and what does a just-culture approach require?
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Respond with compassion and clarity, and separate the person from the system.
What to say: 'I understand you're frightened. I'm not here to punish you. But I have to report this - not to get you in trouble, but because that is how we find out why a 10-fold overdose was possible and stop it happening to someone else. You did the right thing by telling the day nurse. Please keep being honest with me.'
Just-culture principles:
- Distinguish human error from at-risk behaviour from reckless behaviour. A decimal point that was faint on a handwritten order, on a busy ward, at 19:00, is a systems problem first.
- The incident report is not a disciplinary document; it feeds into the safety system. Concealment is the behaviour that is genuinely unacceptable.
- Support the nurse: offer to have a senior colleague with her, acknowledge the emotional impact, and consider whether she needs to be relieved for the rest of the shift.
- Do not promise confidentiality you cannot keep; do not threaten; do not collude.
System fixes to escalate: eliminate handwritten decimal orders, use standard concentrations and tall-man lettering, require independent double-check for opioids, add smart-pump limits, and review staffing and interruption patterns at 19:00.
3. Write the SBAR you would give to the on-call ICU outreach team, and state what you would tell the family.
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SBAR:
- Situation: Mr. K, 78, bed 12, COPD exacerbation, received 10 mg IV morphine instead of 1 mg at 19:00. Now drowsy, RR 8, SpO2 88% on 2 L, BP 102/60, HR 62.
- Background: 58 kg, eGFR 38, no documented opioid tolerance, on home inhalers and prednisolone; no benzodiazepines given. Order was handwritten and the decimal was unclear.
- Assessment: likely opioid toxicity with respiratory depression and hypercapnia risk in COPD; partially responsive to oxygen; naloxone available and prepared; high risk of recurrence given morphine's longer half-life.
- Recommendation: urgent bedside review, consider naloxone infusion and monitored bed, ABG, and senior respiratory review. I will stay at the bedside until you arrive.
Family: call the next of kin, identify yourself, and say plainly: 'Your father was given too much of a strong painkiller by mistake. He is drowsy and his breathing is slow. We have treated him with oxygen and a medicine that reverses the painkiller, and the intensive care team is coming to see him now. We are watching him closely. I am sorry this happened, and we will investigate it fully.' Avoid blame, avoid speculation about fault, give a time for the next update, and document who was told and when.