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Risk Control Strategies for Reducing Patient Harm with HYDROmorphone

  • Differentiate HYDROmorphone from morphine where both products are available (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 morphine
  • Limit the number of strengths available (e.g., do not stock HYDROmorphone 4 mg prefilled syringes in all patient care areas)
  • Avoid stocking HYDROmorphone injection in prefilled syringes in the same strength as morphine prefilled syringes (e.g., do not stock morphine 2 mg and 4 mg and HYDROmorphone 2 mg and 4 mg)
  • Post equianalgesic dosing charts in patient care areas, in computerized prescriber order entry systems and pharmacy information systems, and on medication administration records
  • Limit the starting doses of HYDROmorphone to 0.5 mg (particularly for opioid naïve patients and those with other risk factors such as obesity, asthma, obstructive sleep apnea or those receiving other medications that can potentiate the effects of HYDROmorphone)
  • Employ technology to alert practitioners, (e.g., barcode medication verification, hard stops in smart infusion pump libraries for catastrophic doses)
  • Perform independent double checks when HYDROmorphone is removed from stock, particularly if a pharmacist has not reviewed the order prior to drug administration
  • Strongly consider employing capnography to monitor patients on patient‑controlled analgesia


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