More than TWO could be a clue!


A consumer recently contacted us about a medication error that occurred with her father's prescription. The prescription was for a highly concentrated form of liquid morphine known as Roxanol.

The medication was roxanol error.ismpdispensed 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 (See 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 confirmed that indeed 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, syringes, etc., for a single dose of medication. Before using more than two or three of anything to prepare a medication dose, always first verify with a pharmacist.

Created on April 23, 2014

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