Adverse drug events with HYDROmorphone: how preventable are they?
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Pennsylvania. Patient Safety Authority. ECRI (Organization) Institute for Safe Medication Practices.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Analgesics, Opioid -- adverse effects Dose-Response Relationship, Drug Hydromorphone -- adverse effects Medication Errors -- prevention & control Narcotics -- adverse effects Analgesics, Opioid -- administration & dosage Analgesics, Opioid -- pharmacology Central Nervous System Diseases -- chemically induced Clinical Protocols -- standards Drug Administration Schedule Drug Overdose -- epidemiology Drug Prescriptions Hydromorphone -- administration & dosage Hydromorphone -- pharmacology Morphine -- administration & dosage Narcotics -- administration & dosage Narcotics -- pharmacology Pain Management Receptors, Opioid, mu -- agonists Respiration Disorders -- chemically induced Risk Management Humans United States
- Genre(s):
- Technical Report
- Abstract:
- Despite the fact that HYDROmorphone (Dilaudid(R)) is widely used, there appear to be gaps in understanding its efficacy and potency, which can lead to serious medication errors. Analysts reviewed medication errors and adverse drug reactions (ADR) involving HYDROmorphone that were reported to the Pennsylvania Patient Safety Authority. Seventy percent of the wrong drug reports involved mix-ups with morphine. Wrong dose/overdosage medication error reports show that the most common nodes associated with this event type are administering, prescribing, and dispensing. Review of ADR reports shows that the most common reactions reported involved central nervous system reactions and/or respiratory complications. Sixty-five percent of these adverse reactions appear to have been preventable events. Effective risk reduction strategies include establishing standardized protocols for pain management and protocols for reversal agents that can be administered without additional physician orders when warranted, as well as requiring an independent double check before administering intravenous HYDROmorphone doses.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101542979 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101542979