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