Methadone Intensol 10 mg/mL Med Error

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to cmichalek@ismp.org. 

3 posts / 0 new
Log in or register to post comments
Last post
Wed, 03/04/2026 - 15:07
#1
Henri Valois
Henri Valois's picture
Offline
Last seen: 1 day 2 hours ago
Joined: 07/30/2025 - 13:38
Methadone Intensol 10 mg/mL Med Error

We recently had a med error (10x dosing error) with methadone intensol that was ordered from the med rec (Epic). We only have methadone tablets and methadone intensol 100 mg/10 mL unit dose cups on our formulary. What formulations do you have at your facility? How are you safely dispensing methadone intensol? Any input is appreciated.

Top