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U.S. Department of Health and Human Services

Safety

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Roxanol (morphine sulfate) Concentrated Oral Solution

Audience: Pharmacists and other healthcare professionals

NOTE: A corrected "Dear Healthcare Professional" letter was issued October 22, 2003.

Elan Pharmaceuticals issued a "Dear Healthcare Professional" October 6, 2003 reporting serious adverse events and deaths resulting from accidental overdose of high concentration morphine sulfate oral solutions. In most of these cases, morphine oral solutions ordered in milligrams (mg) were mistakenly interchanged for milliliters (mL) of the product, resulting in 20-fold overdoses. Procedures for proper ordering and dispensing were included in the "Dear Healthcare Professional" letter.

UPDATE

[October 22, 2003 - Corrected Letter - Elan Pharmaceuticals] PDF Format
[June 13, 2003 - Letter - Elan Pharmaceuticals]