We've had several cases lately where pharmacy staff have drawn up 10x the ordered dose for NICU patients. For example, 0.9 mL of clonidine suspension was drawn up instead of 0.09 mL. In one case, the dose made it to the floor before the nurse caught it.

The label shows the dose (0.9 mcg)in 2 different places, in addition to the concentration 10 mcg/mL and the volume 0.09 mL.

We try to avoid dilutions that would result in volumes <0.1 mL, but this med requires a wide dosing range (for a protocol), and having a more dilute product would result in too high of a volume most of the time. We would rather avoid having 2 different dilutions for this med.

We currently don't require 2 RPh checks on NICU meds, as we don't always have enough RPhs on duty to do this consistently.

I'm wondering if 10, 100, etc. dilutions should just be avoided in general for this population? Has anyone heard of this practice or have other ways that your institution prevents this type of error? Thanks for your feedback.