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Publication Type: Medication Safety Alert
Single or Multiple Incident: Multiple
Date: 12/1/2018 12:00:00 AM
Country: Australia

The purpose of this alert is to raise awareness of the potential for dose errors when prescribing and administering clonazepam oral liquid and to recommend a standardised approach to reduce the risk of dose errors. Clonazepam oral liquid is available as a 2.5mg/mL solution in a dropper bottle where one drop contains 0.1 mg clonazepam. Serious incidents have been reported, whereby patients have received incorrect doses up to 10 and 25 times the intended dose. Lack of a standardised unit of measure when prescribing and administering is a major contributing factor in such incidents. Recommendations for safe prescribing, dispensing and administering clonazepam are provided.

Additional Details

Medication/Gas/Fluid:
clonazepam, benzodiazepine, anti-anxiety, opioid, anti-psychotic,


Clonazepam Oral Liquid – Dose Errors