Oops, too much morphine

A resident noticed a human factors problem that led to an accidental overdose of morphine to a patient.  It wasn't fatal, but it led to some concern, and as he notes could be more problematic in other cases.  A good catch for sure by an alert young professional!The problem is with this drug choice given on the Epic electronic ordering system at his hospital:What the problem?  He explains.It is understandable that the nurse gave 20mg of morphine to the patient, since the first number in big blue letters after the word morphine is "20". The actual dose, 10mg, comes after "20MG/ML concentrated oral solution". On a busy shift, while looking up and bringing to the patient 3 or 4 other medications that shift, it would be easy to misread the morphine dose. In fact, several times our team misquoted his dose as 20mg when we discussed the dose with the nurses and the patient.The standard dose is 10-30mg by mouth every 3-4 hours as needed for pain, so a 20mg dose is unlikely to be harmful to an adult patients. However, there are two potentially serious problems that come to mind.First, it certainly could be dangerous for a pediatric patient, since the recommended dose in this population is 0.15 to 0.3 mg/kg. A 20kg child could receive 3.3 times the recommended dose if they were to receive 20mg instead of 6mg, which could lead to respiratory arrest.  (I'm not sure if our hospital has a weight-based dosing similar to the system at pediatric hospitals ).The ...
Source: Running a hospital - Category: Health Managers Source Type: blogs