Published April 23, 2014 (current as of December 24, 2024)
A woman contacted us about an error that occurred with her father's prescription medicine. The prescription was for a highly concentrated form of liquid morphine known as Roxanol.
The medicine was dispensed with a 1 mL syringe. The instructions on the label directed the patient to take 0.5 mL to 7.5 mL of the medicine (Figure 1). The patient's daughter, his caregiver, realized that in order to give the maximum dose she would need to use 8 syringes! Because using 8 syringes seemed unusually high to her, she called the pharmacist to confirm the dose. The pharmacist realized an error did occur and the intended dose was 0.5 mL to 0.75 mL (not 7.5 mL). Thankfully, the error was discovered and corrected before reaching the patient.
It is important to know that it is uncommon to need more than two or three tablets, capsules, vials, ampules, or syringes for a single dose of medicine. If more than two or three of anything is needed to prepare a dose of medicine, contact your doctor or pharmacist to verify that it is correct.
