Morphine dosage error kills elderly patient

by: KIRO 7 Investigative Reporter Chris Halsne Updated:


KIRO 7’s investigative team waited two months for lab results to confirm this: An unlicensed, unregistered nursing aide accidentally killed an elderly Kirkland resident by giving her a massive morphine overdose.

A doctor prescribed 92-year-old Phyllis Conant the equivalent of 0.5 mL of morphine for daily pain relief, but a nurse at the Madison House living facility made a transcription error, omitting the zero and the decimal point.

Before anyone noticed the mistake, the unlicensed aide gave Conant the fatal 5 mL dose of morphine.

And KIRO 7 Investigative Reporter Chris Halsne also learned Madison House continues to operate despite violations for other medication errors.

“I'm angry, I'm resentful, I don't have a lot of understanding in the sense that there are a lot of broken systems there,” said Claire Conant.

Claire Conant knew her mom wasn't in good health, but she figured their daily personal chats and dinners at Madison House would continue for months.

But a long-goodbye was abruptly cut short when, according to state records, Conant "received an overdose of a narcotic medication.” Medical examiners determined her primary cause of death was caused by “acute opiate (morphine) intoxication.”

While Conant’s family expected her loss, they’re reeling from her accidental death.

“My mom was just the most caring, gracious, loving woman I’ve ever met, ever known, it was an honor to have her be my mom,” said an emotional Claire Conant.

In July, after the medication mistake killed Phyllis, the Department of Social and Health Services issued one of its harshest punishments, a six week "Stop Placement Order Prohibiting (new) Admissions" at Madison House.

The assisted living center had already been cited for two other medication errors within the year.

It was during the course of KIRO 7’s investigation that we discovered the aide who administered the lethal dose of morphine to Phyllis wasn't licensed to give such medication. We also uncovered neither she nor the nurse who made the transcription error was disciplined by the state.

 A whistleblowing employee at Madison House risked getting fired to speak with KIRO 7.

“Morally and ethically, I’ve just never seen anything like this,” the employee said.

We’re protecting the whistleblower’s identity to protect them from retaliation.

The worker described an ongoing “chaotic” and “dangerous” environment at Madison House despite state scrutiny.

“It is not better, it’s notably not better,” the whistleblower said. “Nobody is actively practicing what should be in place to prevent medication errors.”

Dr. Yanling Yu of the Washington Advocates for Patient Safety said "sadly, she's not surprised" with the Madison House mistake.

She said Conant is just one of the 225,000 patients who die each year from preventable medical errors. And about half of those fatalities stem from drug dosage mistakes.

“We are an advanced country in technology, supposedly in medicine, so we ought to be able to do better -- to save more lives,” said Dr. Yu.

Claire Conant still can't understand why doctors don't just write an exact prescription for pain medication instead of counting on someone at an assisted living center to convert dosages.

“I’m resentful, especially at the very end, even now in my grieving process this is tainting and marring that whole thing,” Claire Conant said.

An attorney for Madison House responded to our requests for an interview by saying “no comment”.

We also reached out to the staff members directly responsible for the overdose, but no one returned our repeated calls.