RT Journal Article
SR Electronic
T1 Fatal overdoses involving hydromorphone and morphine among inpatients: a case series
JF CMAJ Open
FD Canadian Medical Association
SP E184
OP E189
DO 10.9778/cmajo.20160013
VO 5
IS 1
A1 Amanda Lowe
A1 Michael Hamilton
A1 Julie Greenall BScPhm MHSc
A1 Jessica Ma
A1 Irfan Dhalla
A1 Nav Persaud
YR 2017
UL http://www.cmajopen.ca/content/5/1/E184.abstract
AB Background: Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies.Methods: In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented.Results: We identified 8 cases involving decedents aged 19 to 91 years. The cases involved errors in prescribing, order processing and transcription, dispensing, administration and monitoring. For 7 of the 8 cases, there were multiple (2 or more) possible intervention points. Six cases may have been prevented by additional patient monitoring, and 5 cases involved dispensing errors.Interpretation: Opioid toxicity deaths in patients living in institutions can be prevented at multiple points in the prescribing and dispensing processes. Interventions aimed at preventing errors in hydromorphone and morphine prescribing, administration and patient monitoring should be implemented and rigorously evaluated.