From the May 2006 issue

Although the subject of opiate overdoses caused by accidental mix-ups of opium tincture and paregoric (camphorated opium tincture) has previously been covered in this newsletter (April 2003), we feel it’s worth repeating since we continue to receive reports of this error. Paregoric is used to control diarrhea in children and adults. However, it often is dangerously referred to as camphorated opium tincture, which can be confused easily with opium tincture. Paregoric has 0.4 mg/mL of morphine while opium tincture contains 10 mg/mL–a 25-fold difference in morphine
content.

In a recently reported case, a 75-year-old female was seen at a local emergency department (ED) with complaints of diarrhea. A first-year medical resident prescribed “4 oz. TR Opium” with the directions to take 10 mL every 3 to 6 hours as needed for diarrhea. When the patient had the prescription filled at her local pharmacy, the pharmacist interpreted the prescription as opium tincture rather than the intended paregoric. Unfortunately, he did not recognize that a 10 mL dose of opium tincture would deliver 100 mg of morphine. The patient ingested two doses (200 mg morphine total), became lethargic and was taken to the ED. The patient was administered NARCAN (naloxone) to reverse the overdose and was admitted to the hospital. Thankfully, she survived.

Both opium tincture and camphorated opium tincture are examples of “high alert medications”–drugs that bear a heightened risk of causing significant patient harm when used in error. “High alert medications” require extra precautions be taken when prescribing, dispensing, or administering in order to ensure their safe use. Some strategies to reduce the likelihood of similar errors include:

• Eliminate opium tincture from your inventory, if possible, so that it cannot be dispensed in error.
• Use “paregoric,” the official name for camphorated opium tincture in the US, on all prescriptions, inventory lists (including computer systems), and labels.
• Build alerts into computer systems that advise staff about appropriate dose ranges by metric weight and volume as well as maximum doses.
• Place poison labels on opium tincture containers as well as a label stating the strength of morphine per mL (10 mg/mL) and a statement, “WARNING! Do NOT confuse opium tincture with paregoric.”
• Educate your colleagues and students about these medications and the potential for life-threatening errors if they are confused.

n an effort to help community and ambulatory practitioners identify those drugs that are “high alert,” we have begun to develop a list of High Alert Medications for Community/Ambulatory Practice. Next month we will be asking for your input and evaluation of what should be included on this list. Together we can create a tool to help you focus your medication safety efforts.