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36 RESIDENTS
A NEW NURSE INEXPERIENCED
AS PREPARING FOR SECOND DOSE
AT THIRD DOSE NURSE REALIZED ERROR
BUDDY SHIFTS APPROPRIATE TO LEVEL OF EXPERIENCE
CNA CONFIRMED DOSE TO RN
FACILITY REVIEWED POLICY AND PROCEDURES
FIRST DOSE RN GAVE 25MG
NURSE ASKED CNA TO DOUBLE CHECK DOSE AND AMPULE
NURSE READ AMPULE 10MG/ML
NURSING HOME
ONE REQUIRED SPECIAL ATTENTION
ONE-ON-ONE REVISION OF MEDICATIONS
PATIENT DIED FROM OPIATE OVERDOSE
REVIEW ON NARCOTIC SUBSTANCE PREPARATION
RN ADMINISTERED THE 2ND DOSE
RN GAVE 10X THE PRESCRIBED DOSAGE
RN LOST LICENSE
RN MISREAD AMPULE 1MG/ML
RN UNFAMILIAR WITH MORPHINE
RX 2.5MG OF MORPHINE Q4H
SECOND SHIFT
SET MINIMUM QUALIFICATIONS FOR NURSES IN CHARGE
THREE NURSING ASSISTANTS
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36 RESIDENTS
A NEW NURSE INEXPERIENCED
AS PREPARING FOR SECOND DOSE
AT THIRD DOSE NURSE REALIZED ERROR
BUDDY SHIFTS APPROPRIATE TO LEVEL OF EXPERIENCE
CNA CONFIRMED DOSE TO RN
FACILITY REVIEWED POLICY AND PROCEDURES
FIRST DOSE RN GAVE 25MG
NURSE ASKED CNA TO DOUBLE CHECK DOSE AND AMPULE
NURSE READ AMPULE 10MG/ML
NURSING HOME
ONE REQUIRED SPECIAL ATTENTION
FREE
ONE-ON-ONE REVISION OF MEDICATIONS
PATIENT DIED FROM OPIATE OVERDOSE
REVIEW ON NARCOTIC SUBSTANCE PREPARATION
RN ADMINISTERED THE 2ND DOSE
RN GAVE 10X THE PRESCRIBED DOSAGE
RN LOST LICENSE
RN MISREAD AMPULE 1MG/ML
RN UNFAMILIAR WITH MORPHINE
RX 2.5MG OF MORPHINE Q4H
SECOND SHIFT
SET MINIMUM QUALIFICATIONS FOR NURSES IN CHARGE
THREE NURSING ASSISTANTS
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