Case Medication Control
26-09-2023 -Daughter calls the HAP for father with metastatic colon carcinoma (including heart failure, COPD and lung carcinoma in VG). A palliative care policy has already been implemented for this patient by the patient’s own GP. Since a few hours father has become restless (in the course of the evening). How plucky. Father has been on the morphine pump for a while because of pains and general deterioration. Had a good day during the day but in the evening the picture slowly changed. Home care was still done, there were no details that afternoon.
± 22.00/23.00 hrs: Visiting doctor visits, well approachable patient a bit restless. No pain. Working diagnosis of restlessness in morphine; Due to closed pharmacy around this time, Haldol IM 5mg was given. Advice z.n. again if the unrest continues.
± 5:30 a.m.: 2the visiting doctor. In the early morning, daughter calls the HAP again, because the jab didn’t really help; the patient remains restless and always wants to get out of bed; Didn’t sleep; now also grabs at the abdomen; but CAD ends well; Bijbolus morphine doesn’t help either. This doctor gives 10mg Haldol in response to the advice of previous doctor.
± 8:15 a.m.: Called my own GP; is not going to have to come now a doctor says the family. On arrival very restless patient; approachable but confused; bed parrot torn to pieces in agitation; bijbolus morphine to no avail; had already been done by family; abdomen supple, gray painful male, rochet, pulse 150/min; Then give Midazolam SC, after a good dose only slowly. This led to a plan for palliative sedation.
There should be a spare cassette of Midazolam in the refrigerator, because it was expected that the patient would deteriorate in the short term and palliative sedation was needed. Only then does it come to light that the patient did not have Morphine in the pump but Midazolam! So this was done that afternoon when putting in a new cassette by home care. The patient’s restlessness was therefore caused by pain and no longer being able to express itself properly due to the sleep medication. After discovering the medication error, the patient was given Flumezenil IV as an antidote. The patient woke up but was still restless. In the meantime, the correct Morphine cassette pump had been started again because of the pain. During the course of the day, dyspnea and increase in discomfort. Probably due to heart failure in the patient who was aggravated by the difficult night with a lot of pain. Patient eventually died that evening. Quiet after a one-time Midazolam around 15.00 hours next to the Morphine pump. In view of this happening, I reported this to the inspectorate. All parties involved informed.
For doctors , there is a point of control medication!! In this patient, suffering could have been spared if the error had been detected earlier in this patient. Also, don’t just copy advice/plan from the previous GP.
Pharmacy is going to make stickers on labels clearer with colors. Is arranged within a day. The case was also discussed among the pharmacists.
Home care will have colleagues check (digitally) again for medication alternating pumps.
For me as a GP – if there is Midazolam cassette on hand, have it put in a vegetable drawer by family and not with the morphine cassette.
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