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.
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