Unintentional overdose of morphine sulfate oral solution
HSIB Legacy
Published
Medication
In this investigation we share Len's story. He took an accidental overdose of morphine sulfate oral liquid while at home. We've made two safety observations, relevant to manufacturers of morphine liquids, and to encourage participation in HSIB investigations.
2 observations
Safety Observations (2)
It may be beneficial if manufacturers of morphine oral solution 10mg in 5ml ensure that any dose measurement aid, if supplied with the medication, is able to measure a full range of possible doses.
The intention of this safety observation is to ensure that professional bodies and regulators highlight the importance to their membership of participating in HSIB safety investigations to ensure that all relevant leaning can be obtained.
It may be beneficial if professional bodies provided guidance and further support to their members to maximise the learning that can be achieved from safety investigations that may improve patient care.