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Assignment:
A physician wrote a prescription for ".5 mg IM morphine for postoperative pain" for a 9-month-old infant. The unit secretary recorded the order in the MAR as "5 mg." An inexperienced nurse followed the directions on the MAR without question and gave the baby 5 mg of IM morphine initially and another 5-mg dose 4 hours later. About 2 hours after the second dose, the baby stopped breathing and experienced respiratory arrest. If the physician had written "0.5 mg," the unit secretary would probably not have had any misunderstanding of the intended amount, and the nurse would have administered the correct dose.
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