A physician wrote a prescription for “.5 mg IM morphine for postoperative pain” for a 9-month-old infant. The unit secretary recorded the order in the MAR as “5 mg.” An inexperienced nurse followed the directions on the MAR without question and gave the baby 5 mg of IM morphine initially and another 5-mg dose 4 hours later. About 2 hours after the second dose, the baby stopped breathing and experienced respiratory arrest. If the physician had written “0.5 mg,” the unit secretary would probably not have had any misunderstanding of the intended amount, and the nurse would have administered the correct dose.

Critical thinking Questions

Although the initial error was not the nurse’s, what steps should he or she have taken to avoid this medication error?

What measures could the facility implement to curtail future medication errors?

Explain how using a standardized written measurement system would have prevented this adverse drug event.

What technology is available to help prevent errors and has it been successful?

Note: Provide at least one additional resource in addition to the textbook to answer the question.

Research Question

Substance abuse and misuse have become a national concern. Select a substance, research solutions and provide a plan for your patient. You must support your plan with a minimum of two resources plus the textbook.

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