Morphine and Hydromorphone: An Omnipresent Risk of Mix-ups.

SAFE PRACTICE RECOMMENDATION: Here are some steps to take to reduce the risk of patient harm. 1. Access to hydromorphone should be limited. Stock amounts of hydromorphone should be reduced, whenever possible, and should be eliminated from floor stock entirely if usage is low. The health facility where the error occurred has now removed hydromorphone from every ED in the health care region. If the drug is needed for patient-care units, only the 2-mg/mL strength is available except in palliative-care units. The distribution of other high-potency narcotics is also being revised. The pharmacy continues to stock hydromorphone for compounding patient-controlled analgesia or continuous infusions. 2. Availability of the products should be reduced. a. If both morphine and hydromorphone are available in patient-care units, they should not be stocked in the same strength. Because both drugs are available in 2-mg and 4-mg prefilled syringes in the U.S., hydromorphone 2 mg and morphine 4 mg can be stocked—but not vice versa, because hydromorphone 4 mg could be an excessive dose. b. If both drugs are stored in an automated dispensing cabinet, access to morphine can be allowed in emergencies via an override function, but pharmacy order review should be required before the first dose of hydromorphone is given. c. Each medication should be stored in a separate, individual bin or drawer in the cabinet to help prevent errors in drug selection. d. In the pharmacy, prefilled syringes and vials of hydromorphone and morphine should be segregated, especially if they contain the same concentration. 3. The “look-alike” potential of the prodMr. Grissinger is Director of Error Reporting Programs at the Institute for Safe Medication Practices in Horsham, PA (www.ismp. org). Morphine and Hydromorphone An Omnipresent Risk of Mix-ups