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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 - one drop contains 0.1 mg clonazepam. Serious incidents have been reported where patients have received incorrect doses up to 10 and 25 times the intended dose. Recommendations to prevent dosing errors with oral liquid clonazepam are provided.

Additional Details

Device:
dropper, spoon, measuring cup
Medication/Gas/Fluid:
benzodiazepines, clonazepam (Rivotril®), opioids, antipsychotics
Medication/IV List:
narcotics/opiates, IV, transdermal, and oral


Clonazepam Oral Liquid – Dose Errors