Adverse drug events with HYDROmorphone: how preventable are they?

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
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