Dilaudid

OPIOID SWAP

An ED physician ordered morphine, 10 mg I.M., for a 69-year-old patient with a chest injury who was being discharged. The narcotics drawer contained both hydromorphone and morphine in 1 ml, 10 mg/ml ampules, and the patient mistakenly received 10 mg of hydromorphone I.M., a dose equivalent to 60 to 70 mg of morphine. Shortly after he left, a nurse discovered the error during a scheduled opioid count. When the hospital staff finally located the patient, he was in another hospital ED near his home because his condition had deteriorated. He soon had a cardiac arrest and died.

Mix-ups between morphine and hydromorphone are among the most common and serious errors involving high-alert drugs. Here are some safety strategies:

* Reduce stock amounts of hydromorphone or eliminate it from unit stock entirely if it's used infrequently.

* If both morphine and hydromorphone are available in patient-care units, avoid storing them in the same strength. Both drugs are available in 2 mg and 4 mg prefilled syringes, so the pharmacy could stock 2 mg doses of hydromorphone and 4 mg doses of morphine (but not vice versa, because 4 mg of hydromorphone could be an excessive dose). Each medication should also be stored in a separate, individual bin to help prevent selection errors.

* Reduce "look-alike" potential by using tall man lettering, such as HYDROmorphOne on drug labels, MARs, and listings on computer screens or automated dispensing cabinets. Reminder labels on hydromorphone containers can indicate the brand name equivalent "Dilaudid" to help prevent confusion.

* Always have another individual perform an independent double check before you administer I.V. opioids.

* Monitor patient responses. Your facility needs policies specifying the scope, frequency, and duration of monitoring required before patients who've received a parenteral opioid leave the unit or the hospital.

Copyright Springhouse Corporation Nov 2004
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