• paracetamol
• drug formulary management
• medical errors
• neonatology
• paediatrics
• pain management
• quality management
• intravenous administration

The risks of accidental 10-fold errors in the administration of intravenous paracetamol have been well publicised in the UK by the Medicines and Healthcare products Regulatory Agency1 and the National Patient Safety Agency.2 These errors can arise where the dose in milligrams is confused with the dose in millilitres. The risk is compounded by the presentation of intravenous paracetamol in vial sizes which exceed the required dose.

Dose volumes for children weighing less than 10 kg are less than 10 mL. Originally, the only intravenous paracetamol products licensed for children of all ages were 500 mg/50 mL bottles and 1000 mg/100 mL bottles. While these products contained the same concentration of paracetamol in mg/mL …