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Intravenous morphine administration on neonatal units | Signal

Issue date25 March 2011
This Signal is about the risks of inaccurate morphine administration to neonates.

A sample incident reads:

“I received a telephone call from a nurse to say that she believed a mistake had been made with the morphine infusion for this baby. She had made it up without diluting the morphine appropriately so the infusion was 10 x stronger than prescribed.” 

It is routine practice within neonatal units to administer intravenous morphine to babies requiring mechanical ventilation. The BNF for Children recommended dosage regime is a loading dose of 50 micrograms/kg by slow intravenous injection followed by a maintenance dose of 5 – 20 micrograms/kg/hour by continuous intravenous infusion, although higher doses are sometimes necessary. This drug preparation is a complex procedure as it necessitates a series of calculations.
Following a trigger incident, a search of the National Reporting and Learning System (NRLS) was undertaken to identify incidents relating to the use of intravenous morphine on neonatal units, which occurred between 1 April 2008 and 1 November 2010. A sample of 74 incidents were analysed and the following themes identified:
  • incorrect dose prescribed to make up an infusion (e.g. 10mgs /kg prescribed instead of 1mg /kg)
  • incorrect dose calculated when preparing syringe (e.g. 600mcg drawn up instead of 60mcg)
  • incorrect dilution prepared (dose diluted in 10 ml solution instead of 20 ml solution)
  • incorrect rate administered via syringe pump (e.g. pump set at 0.5mls/hr instead of 0.05mls/hr)

Many of these incidents resulted in 10 times dosing errors and in four cases the incident resulted in severe harm.

To minimise the risks, neonatal units should ensure that protocols relating to the preparation and administration of intravenous morphine for neonates are clear and easy to follow. For example, steps should be outlined separately in a checklist format. In addition, the use of pre-filled syringes from a Central Intravenous Additive Service (CIVAS) and smart pumps should be considered.

We would like to hear from you - please contact us with your initiatives to reduce risks in these areas.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.