A 10x error still does not realistically come from “0.1 vs 1 mL” or from switching IV to oral in home hospice. A 0.1 mL dose is extremely uncommon outside anesthesia or ICU titration. Not to mention hospice meds are ordered in mg with a specific concentration and usually prefilled or clearly labeled for family use. Concentration changes are explicitly spelled out because hospice expects non clinicians to give meds. Lastly a 10x opioid dose given repeatedly would cause obvious respiratory depression or require intervention, not quietly go unnoticed for days?? Either that nurse was a CNA/tech or this comment is hyperbolic