Life Threatening Morphine Errors

This is a topic that can’t wait anymore. Math. I said it, please don’t stop reading, this may help you or someone you care about prevent a devastating medication error. While most medications errors do not impact patient health, there is a medication error I see happen that can: Errors involving concentrations of liquid dosage forms. Liquid oral morphine is the classic example of a drug that has numerous strengths and liquid concentrations. The two concentrations I see most often are the concentrated morphine at 20mg/ml and also I will occasionally see 10mg/5ml. If these two concentrations get messed up, you are looking at a 10-fold error. Take 2.5 mls of the 10mg/5ml dose, and you get a 5 mg dose. If the concentrated morphine was (in error) dispensed, administered, or written for, you are looking at a 50 mg dose! If you get easily confused with these conversions, you must ask for help to double check your work. Please remember to look and think about the concentration of a liquid you are using as I’ve seen this situation end badly before and don’t want to see it again.

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Written By Eric Christianson

July 16, 2014

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