Finding an optimal dose: considerations in accurate opioid dispensing

Morphine sulfate is widely prescribed for the relief of moderate to severe acute and chronic pain. Unfortunately, medication errors associated with morphine sulfate can result in patient harm; profound respiratory depression can result from excessive doses in opioid-naïve patients. An actual medication order containing a potentially toxic overdose of morphine sulfate is examined. Patients habituated to high doses of morphine sulfate are at risk from underdosing, a hazard also of concern.