Licensure/ Standards of Practice

Mrs. Jones and the Overdose

Shortly after noon, Mrs. Jones was admitted to the community hospital for treatment
of pancreatitis. She complained of significant abdominal pain and was placed in the
critical care ward. When Ms. Andersen, a nurse who had worked for the hospital for
nearly ten years, began her shift at three o’clock, she assumed responsibility for Mrs.
Jones. She was also responsible for four other seriously ill patients, including one
child with a seizure disorder and a man receiving multiple blood transfusions for a GI
bleed. Mrs. Jones was still complaining about her intense pain, even though she had
received pain medication a few hours earlier. (Demerol 50mg IM q 4-6 hours prn.)
She was also uncomfortable because the medication made her itch. Nurse Andersen
had called Dr. Smith’s office and left a message asking him to change the pain
medication orders. Before speaking with him, however, Nurse Andersen was called to
the Emergency Room. While assisting with the procedure in the ER, Dr. Smith called
the hospital and changed Mrs. Jones’ pain management orders to morphine 8-10mg
IM q 3-4 hours prn.

Mrs. Brown, a relatively new nurse to the hospital, was covering Nurse Andersen’s
patients while she was assisting in the ER. Nurse Brown received the message that the
medication order for Mrs. Jones had been changed. Since Mrs. Jones was not her
patient she decided to leave the order sheet sitting at the unstaffed nurses’ station to be
transcribed later by Nurse Andersen. Due to down time status Nurse Brown obtained
the medication from the narcotics drawer on an override, she did not record this on the
narcotics check out sheet. She intended to record it after she had given Mrs. Jones the
medication. Nurse Brown went straight to Mrs. Jones’ room, told her the doctor had
prescribed a new medication and gave her morphine 8mg IM. On her way to chart the
medication, Nurse Brown met the parents of the young child. They frantically asked
for help because their child was having a seizure. Nurse Brown remained in the room
with the child and the parents for about 15 minutes.

Meanwhile, Nurse Andersen returned from the ER and was glad to see the new pain
management orders for Mrs. Jones sitting on the desk. She transcribed the orders in
the patient’s chart. She also looked at the narcotics check out sheet but saw no
notation for pain medication since she left the floor. Nurse Andersen knew that Mrs.
Jones had complained about her pain for a long time so hurriedly she obtained the
medication from the narcotics drawer and gave morphine 10mg IM to Mrs. Jones.
Upon returning to the nurses’ station, Nurse Andersen encountered Nurse Brown and
they quickly discovered that Mrs. Jones had received two doses of morphine, one
from each of them.
What are the concerns in this scenario?

What are the next steps the nurses should take?

What safety procedures need to be implemented during down time instances?

What do you believe should happen to the nurses?