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 mg.5
  • 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


  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.


How to cite: Institute for Safe Medication Practices (ISMP). Risk control strategies for reducing patient harm with HYDROmorphone [Poster]. Horsham, PA: ISMP. 2017.

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