I know someone who made an egregious error with duramorph, it was not as innocuous as underdosing and the calculation was even simpler. Shocking really. And yes, this is math that a fourth-grader could easily perform with a pencil and paper and about two seconds' thought.OK. Revisiting yet another incredible blunder by the same MD. I really didn't think anything could top what the original topic of this thread.....but he did. As many of you have probably already experienced, we have had a drug short, this time of Duramorph. The 1mg/ml variety which we have had for many years. Somehow, the pharmacy found us some Duramorph that is .5mg/ml...half the strength. When I relieved the CRNA at 1900 this evening, she told me of an interaction that she had with the above mentioned MD. He asked how much Duramorph she was going to give. She replied .2mg. He then asked how much volume that was going to be. She told him 0.4ml. He told her that was too much....even though he was aware that the Duramorph was .5mg/ml. She again advised him that this Duramorph was half as strong as the Duramorph that we had been getting for the last decade or so. He still insisted that this was too much and went into some mathematical diatribe, explaining his thinking/method. She had the CRNA so confused and doubting herself, assuming that the MD MUST know what he is talking about, that she caved and gave the dose he wanted which was .2ml.....or 0.1mg. Now...is this not nursing math 101? And, why can't he TRUST that this CRNA who was an RN before he was born, JUST MIGHT BE RIGHT? Truth is stranger than fiction!! Just when I thought I had seen it all.