Oops, Also Much Morphine
Thursday, November 25, 2021
A resident noticed a human factors work that led to an accidental overdose of morphine to a patient. It wasn't fatal, exactly it led to to a greater extent than or less concern, in addition to every bit he notes could last to a greater extent than problematic inwards other cases. A expert grab for sure past times an warning immature professional!
The work is amongst this drug selection given on the Epic electronic ordering organization at his hospital:
What the problem? He explains.
It is understandable that the nurse gave 20mg of morphine to the patient, since the get-go publish inwards big blueish letters afterward the give-and-take morphine is "20". The actual dose, 10mg, comes afterward "20MG/ML concentrated oral solution". On a busy shift, acre looking upward in addition to bringing to the patient iii or four other medications that shift, it would last slow to misread the morphine dose. In fact, several times our squad misquoted his dose every bit 20mg when nosotros discussed the dose amongst the nurses in addition to the patient.
The criterion dose is 10-30mg past times rima oris every 3-4 hours every bit needed for pain, in addition to therefore a 20mg dose is unlikely to last harmful to an adult patients. However, at that topographic point are 2 potentially serious problems that come upward to mind.
First, it for certain could last unsafe for a pediatric patient, since the recommended dose inwards this population is 0.15 to 0.3 mg/kg. A 20kg nipper could have 3.3 times the recommended dose if they were to have 20mg instead of 6mg, which could Pb to respiratory arrest. (I'm non sure if our infirmary has a weight-based dosing similar to the organization at pediatric hospitals ).
The 2d affair that is concerning is that the FDA mandated changing the labeling of the drug from 20mg/ml to 100mg/5ml, in addition to required that a bold warning last placed on each bottle stating "ONLY FOR USE IN PATIENTS WHO ARE OPIOID TOLERANT", since several deaths accept occurred from misunderstandings of the concentration (for example, assuming the dose of 20mg meant 20ml). It is possible that the concentration used past times the chemist's shop is different from what is labeled on Epic, or that the nurses encounter a different label than I do, exactly if not, this could last a setup for a severe overdose.
On the "favorites list," 20mg/ml is the solely liquid cast available on Epic at our hospital. I volition double banking concern stand upward for tomorrow if whatever other concentrations are available inwards the total formulary in addition to allow you lot know. The other generic forms, according to UpToDate, are 2mg/ml in addition to 4mg/ml. Most patients locomote pills instead, exactly since our patient had problems swallowing pills nosotros had to locomote the liquid.
Next day:
I checked on the morphine ordering in addition to it turns out they create accept the 10mg/5ml dose cups available here. I recall this is what the patient received, since he said "she gave me 2 cups instead of one" afterward the dosing error. It seems similar although nosotros placed the club for concentrated solution, the nurse is allowed to administer the medication inwards to a greater extent than or less other cast if she wishes.
Strangely plenty though, the 10mg/5ml cast does non appear on the favorites listing at our hospital. The solely cast that is at that topographic point is the 20mg/ml form. This is likely why that was the cast that the
resident ordered. To instruct the 10mg/5ml cast you lot accept to become to the total formulary list. The favorites listing changes depending on where inwards the infirmary the patient is (for example, solely the morphine PCA in addition to injections come upward up on the favorites listing when the patient is inwards the pre-op area, whereas the 20mg/ml concentrated oral solution, tablets in addition to injections appear on the listing when they are on the floor).
The work is amongst this drug selection given on the Epic electronic ordering organization at his hospital:
What the problem? He explains.
It is understandable that the nurse gave 20mg of morphine to the patient, since the get-go publish inwards big blueish letters afterward the give-and-take morphine is "20". The actual dose, 10mg, comes afterward "20MG/ML concentrated oral solution". On a busy shift, acre looking upward in addition to bringing to the patient iii or four other medications that shift, it would last slow to misread the morphine dose. In fact, several times our squad misquoted his dose every bit 20mg when nosotros discussed the dose amongst the nurses in addition to the patient.
The criterion dose is 10-30mg past times rima oris every 3-4 hours every bit needed for pain, in addition to therefore a 20mg dose is unlikely to last harmful to an adult patients. However, at that topographic point are 2 potentially serious problems that come upward to mind.
First, it for certain could last unsafe for a pediatric patient, since the recommended dose inwards this population is 0.15 to 0.3 mg/kg. A 20kg nipper could have 3.3 times the recommended dose if they were to have 20mg instead of 6mg, which could Pb to respiratory arrest. (I'm non sure if our infirmary has a weight-based dosing similar to the organization at pediatric hospitals ).
The 2d affair that is concerning is that the FDA mandated changing the labeling of the drug from 20mg/ml to 100mg/5ml, in addition to required that a bold warning last placed on each bottle stating "ONLY FOR USE IN PATIENTS WHO ARE OPIOID TOLERANT", since several deaths accept occurred from misunderstandings of the concentration (for example, assuming the dose of 20mg meant 20ml). It is possible that the concentration used past times the chemist's shop is different from what is labeled on Epic, or that the nurses encounter a different label than I do, exactly if not, this could last a setup for a severe overdose.
On the "favorites list," 20mg/ml is the solely liquid cast available on Epic at our hospital. I volition double banking concern stand upward for tomorrow if whatever other concentrations are available inwards the total formulary in addition to allow you lot know. The other generic forms, according to UpToDate, are 2mg/ml in addition to 4mg/ml. Most patients locomote pills instead, exactly since our patient had problems swallowing pills nosotros had to locomote the liquid.
Next day:
I checked on the morphine ordering in addition to it turns out they create accept the 10mg/5ml dose cups available here. I recall this is what the patient received, since he said "she gave me 2 cups instead of one" afterward the dosing error. It seems similar although nosotros placed the club for concentrated solution, the nurse is allowed to administer the medication inwards to a greater extent than or less other cast if she wishes.
Strangely plenty though, the 10mg/5ml cast does non appear on the favorites listing at our hospital. The solely cast that is at that topographic point is the 20mg/ml form. This is likely why that was the cast that the
resident ordered. To instruct the 10mg/5ml cast you lot accept to become to the total formulary list. The favorites listing changes depending on where inwards the infirmary the patient is (for example, solely the morphine PCA in addition to injections come upward up on the favorites listing when the patient is inwards the pre-op area, whereas the 20mg/ml concentrated oral solution, tablets in addition to injections appear on the listing when they are on the floor).