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Fatal overdoses involving hydromorphone and morphine among inpatients: a case series
Amanda Lowe1, Michael Hamilton1, Julie Greenall BScPhm MHSc1
1Office of the Chief Coroner for Ontario (Lowe), Toronto, Ont.; Institute for Safe Medication Practices Canada (Hamilton, Greenall, Ma); St. Michael's Hospital, Health Quality Ontario and Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto (Dhalla); Department of Family and Community Medicine, St. Michael's Hospital, and Department of Family and Community Medicine, University of Toronto (Persaud), Toronto, Ont.
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.