Date of incident: 16/02/2022

Error type: dispensing error

Patient age: 69

Patient sex: female

Brief summary of incident: Morphine dose appropriateness not confirmed and was an extremely high and unsafe dose

Name of medication: Oramorph oral conc 20mg/ml;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Patient would have went into respiratory depression

Possible cause/contributory factors: Mix up with prolonged release preparations

Reasons why incident occurred and actions required to prevent reoccurence:
Query high doses of opioids

Best description of this error/near miss:
wrong dose strength