Drug manufacturer Elan Pharmaceuticals has issued a safety alert for concentrated oral morphine sulfate solution, 20 mg/ml. Generally prescribed for patients with severe chronic pain, this concentration is 20 times stronger than the more commonly used 1 mg/ml solution. Rather than labeling the concentrated form as 20 mg/ml, some manufacturers label it as 100 mg/5 ml (5 ml equals a teaspoonful). If the prescriber orders morphine sulfate in milliliters-such as 10 ml rather than 10 mg-the patient could receive a 20-fold overdose if the concentration isn't specified and the wrong concentration is used.

If possible, avoid storing concentrated morphine sulfate in patient-care units. If it must be stored in a patient-care unit, make sure it has an auxiliary label and store it away from conventional concentrations. Remove it from the unit when the drug is discontinued.

Don't carry out an order for any liquid medication ordered by volume unless the dose in milligrams is included.