Occasionally the "wrong strength" has been prescribed and pharmacists are asked to query strengths where appropriate in palliative care patients.
Catherine Baldridge, medication safety officer, based at South Tyneside Trust said "Community nurses are continuing to report some prescribing of the ‘wrong strength’ of midazolam. Instead of prescribing the 10mg in 2ml as recommended in palliative patients they are prescribing the 1mg in 1ml preparation or the 10mg in 5ml. We have had one error where the patient got the wrong dose administered. The reason that the 10mg in 2ml should be prescribed/dispensed is because of the volume issue with the more dilute preparations. The usual starting dose of midazolam is 2.5mg and is increased from there – the dose will be administered sub-cutaneously and therefore the concentrated preparation needs to be used to reduce the volume required".