Morphine overdose in a newborn and the search for the third order 'why?'

A premature infant with pneumothorax-complicating respiratory distress syndrome died following a massive (100 fold) morphine overdose prior to insertion of an intercostal drain. The subsequent inquest considered the circumstances in which this error occurred and an open verdict was recorded. Adverse drug events remain an important cause of morbidity and mortality in hospital. A systems analysis approach to such incidents has been advocated as the most likely way to help minimize the risk of drug errors.