1 | 81 | Female | Hospital | Ordered: hydromorphone 1 mg (0.5 mL from 2 mg/mL vial) subcutaneously | Administered: morphine 25 mg (0.5 mL from 50 mg/mL vial) subcutaneously | About 5-fold excessive dose |
2 | 22 | Male | Hospital | Initial order: morphine increased from 5 to 10 mg intravenously every 2 hours
| Increased to: hydromorphone 5 to 10 mg intravenously every 4 hours as needed | About 5-fold excessive dose |
3 | 82 | Male | Palliative care | Ordered: hydromorphone increased from 0.2 to 0.4 mg subcutaneously as necessary for pain management | Administered: hydromorphone 4 mg (dose drawn from a 10 mg/mL concentration vial to give an actual dose of 4 mg) | About 10-fold excessive dose |
4 | 86 | Male | Nursing home | Ordered: hydromorphone 0.2 mg/h intravenously. | Administered: hydromorphone 2 mg/h intravenously | About 10-fold excessive dose |
5 | 90 | Female | Hospital | Initial order: long-acting morphine 15 mg twice daily Second order: discontinuation of morphine; hydromorphone 2 mg orally every 4 h as needed | Administered: both morphine and hydromorphone administered | About 2.5-fold excessive dose |
6 | 42 | Female | Hospital | Ordered: morphine 2 to 3 mg intravenously every 4 h as needed | Administered: hydromorphone 3 mg intravenously | About 5-fold excessive dose |
7 | 19 | Female | Hospital | Ordered: hydromorphone 4 mg intravenously | Administered: hydromorphone 4 mg intravenously | Administration despite sedation |
8 | 91 | Female | Hospital | Ordered: morphine 4 mg subcutaneously | Administered: hydromorphone 4 mg subcutaneously | About 5-fold excessive dose |