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.