Following reports of a patient safety incident in Northern Ireland in the Spring 2017 Medicines Management Team newsletter, pharmacists are advised to be increasingly careful when supplying concentrated morphine sulphate solution 20mg/ml (Oramorph).

The Northern Ireland medicines management team reported a recent incident where a prescription was written for:

“Morphine sulphate 20mg/ml x 20ml, give 20mg when required for pain every four to six hours”

The pharmacy replicated the dose onto the dispensing label but the patient’s family interpreted the dose to mean 20ml when required, and administered the full 20ml or 400mg dose. This resulted in the patient receiving twenty times the intended dose, and needing opioid reversal treatment.

Prescribers and community pharmacists have been advised:

• To take extra care when prescribing or dispensing oral opioid liquids. It is recommended that the high strength liquids are reserved for use where medical and/or nursing staff are concerned that the patient is unable to swallow a larger dose of the more dilute, lower strength solution.
• Where a dose is expressed as mg on the prescription, it is advisable to also specify the number of ml that should be taken on both the prescription and dispensing label.
• Where a small or unusual quantity is prescribed the pharmacist should supply an appropriate size oral syringe and counsel the patient and/or carer appropriately on the correct dose to be taken.
• Pharmacists should always review prescribed opioid doses to confirm they are appropriate for the patient.
• Healthcare professionals prescribing or dispensing opioid liquids should always counsel the patient and/or carer to ensure they understand the appropriate dose.