NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Morphine injection: care required

NHSGGC Acute services have highlighted potential for error between morphine 10mg/ml and 1mg/ml injections. This could be at various different stages of use such as ordering, issue, receipt, recording and administration.


Key messages

  • Orders must include the correct formulation, strength and ampoule size, eg morphine sulphate 10mg/ml, 1ml amp, 1x10 required.
  • Pharmacy staff must checks any ambiguous requisition before supply, preferably with the nurse in charge or who completed the order.
  • Read the label thoroughly at all stages of use.
  • Do not rely on colour, packaging, manufacturer name or ampoule size in the identification or checking process.
  • Ensure that fully independent second checks are used where possible at selection, preparation and administration.
  • If you need different strengths of morphine, can they be separated in storage to prevent selection errors?


There are risks of a patient being administered either one-tenth of the intended dose with subsequent effects on pain control, or being administered ten times the intended dose which could result in overdose. 


Of particular concern is the potential for confusion between the preservative-free intrathecal morphine amps (1mg/ml,1ml amp) and the preservative containing morphine amps (10mg/ml, 1ml amp). Intrathecal administration of a preservative-containing product when a preservative-free product is intended could be catastrophic.


morphine amps


If ordering morphine 1mg/ml, ensure a volume is stated to prevent ambiguity about whether the 50ml vial or 1ml ampoule is required.

morphine 1




Published 02/02/2017