From the July 1, 2004 issue
ISMP Canada recently received an error report in which
a 69-year-old patient was given 10 mg of hydromorphone IM
instead of 10 mg of morphine. The error may have contributed
to the patient's death. The patient presented to the ED with
a chest injury sustained while horseback riding. Prior to
discharge, the ED physician wrote an order for morphine 10
mg IM for pain, but hydromorphone was mistakenly selected
from a narcotic drawer. Both hydromorphone and morphine were
stocked in 1 mL, 10 mg/mL ampoules. In Canada, the two products
are visually distinct in appearance; nevertheless, the names
are similar and the concentrations are identical. According
to equianalgesic dose conversion charts, the patient, who
was likely opiate-naïve, received an equivalent dose
of about 60 to 70 mg of morphine. Shortly after the patient
was discharged, the nurse discovered the error after a scheduled
narcotic count showed a discrepancy between the two drugs.
Hospital staff immediately tried to contact the patient, and
finally located him in a rural hospital ED close to his home.
By then, the patient's condition had deteriorated, and he
arrested a short time later. Despite rescue efforts, the patient
Over the years, we've received many reports of confusion
between hydromorphone and morphine, some of which have been
fatal. In fact, mix-ups between these drugs are among the
most common and serious errors that can occur involving
two high-alert drugs. It's a risk that exists in almost
every acute care facility. Assume that this error will eventually
happen in your facility, and take the following steps now
to reduce the risk of patient harm.
Limit access. Reduce stock amounts of hydromorphone
wherever possible, and eliminate it from floor stock entirely
if usage is low. For example, the health system where this
error occurred has now removed all hydromorphone from every
ED in the health region. If the drug is needed on patient
care units, only the 2 mg/mL strength is available, except
in palliative care units. The distribution of other high
potency narcotics is also being revised. The pharmacy will
continue to stock hydromorphone for compounding PCA or continuous
Reduce options. If both drugs are available in patient
care units, avoid stocking morphine and hydromorphone in
the same strength. For example, since both drugs are available
in 2 mg and 4 mg prefilled syringes (in the US), stock 2
mg of hydromorphone and 4 mg of morphine (but not vice versa,
since 4 mg of hydromorphone could be an excessive dose).
If the drugs are stored in an automated dispensing cabinet,
consider allowing access to morphine via an override function
in emergencies, but require pharmacy order review before
removing a first dose of hydromorphone. Also be sure to
store each medication in a separate, individual bin or drawer
in the cabinet to help prevent drug selection errors. In
the pharmacy, segregate prefilled syringes and vials of
these drugs, especially if they contain the same concentration.
Reduce "look-alike" potential. When able,
use tall man lettering to emphasize the "HYDRO"
portion of hydromorphone on pharmacy labels, auxiliary labels,
medication administration records, and drug listings on
computer screens or automated dispensing cabinets. Consider
adding label reminders on hydromorphone indicating the brand
name equivalent, "DILAUDID," to help prevent
confusion. Some automated dispensing cabinets may also offer
the capability of asking, "This is DILAUDID.
Is that correct?" when nurses retrieve hydromorphone.
Require redundancies. Require an independent double
check before administering IV narcotic doses. Since nurses
routinely obtain narcotics from floor stock, the typical
pharmacist-nurse double-check is not in place (as it is
with specific patient doses dispensed from the pharmacy).
Some automated dispensing cabinets can be programmed to
require a "witness" when selected narcotics are
removed, or when the override feature is used to access
selected narcotics. Reminders can also appear on the screen.
Educate staff. Provide safety information on the
use of potent narcotics via newsletters and in services.
Educate staff about the differences between hydromorphone
and morphine, as some of the reported mix-ups have been
due to the mistaken belief that hydromorphone is the generic
name for morphine.
Employ technology. Technological solutions (e.g.,
bar coding, automated dispensing technology that requires
pharmacy order screening prior to dose retrieval) may reduce,
but not eliminate, the risk of mix-ups.
Educate patients. Prior to administration of a narcotic,
repeat the name of the medication out loud to the patient
as another source of confirmation.
Monitor patients. Implement policies that specify
the scope, frequency, and duration of monitoring that should
occur before discharging patients who have just received
a parenteral narcotic.