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A 19-month-old boy was admitted to the emergency department (ED) of a small community hospital after an automobile accident. He was screaming from the severe pain of a leg fracture, so the doctor ordered 2 mg of morphine liquid, to be given orally. Several hours later, the boy died from a morphine overdose. His autopsy revealed that he'd received approximately 20 times the ordered dose.
Although morphine solutions come in concentrations of 2 mg/ ml and 4 mg/ml, this hospital had only Roxanol, 20 mg/ml, which is usually given to cancer patients. The cap on a Roxanol bottle has a calibrated dropper marked 1 ml, 1.5 ml, and 2 ml.
The ED nurse should have drawn up O. 1 ml of Roxanol, but that amount wasn't scored on the dropper. She may have measured 2 m1 on the dropper, thinking it was 2 mg-the correct dose. Or, she may have drawn up 1 ml (20 mg), incorrectly interpreting it as 0.1 ml.
Administering morphine to a child requires extreme caution. Liquid doses are best prepared and labeled by pharmacists, using special oral syringes that won't accommodate a needle. Dose calculations and preparations should be checked by at least two people-ideally, a pharmacist and a nurse, who could also doublecheck their interpretations of the order. Concentrated morphine should be kept only in the pharmacy. It's too dangerous to be on the unit, where it may be misused.