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Risk Control Strategies for Reducing Patient Harm with HYDROmorphone


  • Differentiate HYDROmorphone from morphine where both products are available1-3
    -Use tall man lettering on labels, order sets, order entry screens, medication administration records, etc
  • Include the brand name Dilaudid on order sets, order entry screens, medication administration records, etc, to help differentiate HYDROmorphone from morphine1-3
  • Limit the number of strengths available1
  • Avoid stocking HYDROmorphone in prefilled syringes in the same strength as morphine prefilled syringes4
  • Post equianalgesic dosing charts in patient care areas, in computerized prescriber order entry systems and pharmacy information systems, and on medication administration records1
  • Limit the starting dose of HYDROmorphone to 0.5 mg3,4
– Particularly for opioid-naïve patients and those with other risk factors such as obesity, asthma, or obstructive sleep apnea or those receiving other medications that can potentiate the effects
of HYDROmorphone

– The initial dose should be reduced in the elderly or debilitated and may be lowered to 0.2 mg5
  • Perform independent double checks when HYDROmorphone is removed from stock, particularly if a pharmacist has not reviewed the order prior to drug administration1
  • Strongly consider employing capnography to monitor patients
    on patient-controlled analgesia6
  • Employ technology to alert practitioners such as barcode medication verification and hard stops in smart infusion pump libraries for catastrophic doses4,6

References: 1. Hicks, RW, Becker, SC, and Cousins, DD. (2006). MEDMARX® Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety. 2. Patient Safety Authority. Common Medication Pairs that Contribute to Wrong Drug Errors. PA-PSRS Patient Saf Advis. 2007 Sept;4(3):1-2. 3. Institute for Safe Medication Practices (ISMP). ISMP Medication Safety Alert, Acute Care. 2011;16:1-3. 4. American Society of Health System Pharmacists, Inc. Proceedings of a summit on preventing patient harm and death from i.v. medication errors. Rockville, MD; July 14-15, 2008. Am J Health-Sys Pharm. 2008;65:2367-2379. 5. Dilaudid® (HYDROmorphone HCl) Injection, USP [package insert]. Fresenius Kabi; 2016. 6. The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5.


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