Download Hydromorphone Safety - PowerPoint

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Bad Pharma wikipedia, lookup

Pharmacogenomics wikipedia, lookup

Adherence (medicine) wikipedia, lookup

Electronic prescribing wikipedia, lookup

Bilastine wikipedia, lookup

Transcript
Safe use of HYDROmorphone
CLINICAL EXCELLENCE COMMISSION
Medication Safety and Quality Unit
February 2016
Session Objectives:
The objectives of this presentation are to:
• Provide a brief overview of HYDROmorphone
formulations available
• Describe recognised risks associated with
HYDROmorphone storage and handling
• Discuss strategies to address risks
2
What is HYDROmorphone:
• It is a potent opioid analgesic
• It is used to manage moderate to severe
acute or chronic pain
• It is 5 – 7 times STRONGER than morphine
• HYDROmorphone is NOT morphine
• Errors involving its use can result in fatal
over-dose
3
HYDROmorphone formulations
•
HYDROmorphone is manufactured in a variety of oral
and injectable formulations
•
Oral formulations include:
• tablets – variety of strengths, including immediate
release and modified release
• oral liquid
•
Injectable formulations include:
• 2mg/ml and 10mg/ml (high potency)
4
HYDROmorphone overdose
symptoms
• respiratory depression
• extreme drowsiness
• cold and/ or clammy skin
• pupillary constriction
• bradycardia and hypotension
5
(MIMS Australia, 2015)
HYDROmorphone incidents
• Fatal and near fatal overdose incidents have
been reported within Australia and
internationally
• In 2013 HYDROmorphone was the 15th most
frequently reported medicine in clinical
incidents in NSW
(NSW Clinical Excellence Commission, 2014)
6
Errors associated with HYDROmorphone
use have arisen from:
• Complexity of branded products leading to
incorrect product selection
• Use of fractional doses
• Confusion between look-alike, sound-alike
names of HYDROmorphone and morphine
7
Complexity of branded products
Hydromorphone is available in multiple
strengths and dose forms:
• Immediate release tablets
• Immediate release oral liquid 1mg/ml
• Controlled-release tablets
• Injectable - immediate release and highpotency
8
Immediate release tablets
Dilaudid® tablets
• Available in 2mg, 4mg, 8mg strengths
• May be given several times a day
9
Immediate release oral liquid
Dilaudid® oral liquid 1mg/ml
• May be given several times a day
10
Controlled release tablets
Jurnista® controlled release tablets
• Available in 4mg, 8mg, 16mg, 32mg, 64mg strengths
• Only given once a day
11
Injectable formulations
Injectable Dilaudid® 2mg/ml
Available as 1mL ampoules
12
High-potency injectable
Injectable Dilaudid® – HP high-potency 10mg/ml
Available as 1mL, 5mL and 50mL ampoules
13
Case 1: Complexity of branded
products
A patient was prescribed oral HYDROmorphone 4mg
modified release once a day.
The nurse erroneously administered 4mg of an
immediate release HYDROmorphone formula.
Fortunately there was no adverse outcome for the
patient.
14
Use of fractional doses
• Fractional doses may be necessary due to
the high potency of HYDROmorphone
e.g. HYDROmorphone 0.25mg
• They can lead to errors associated with
incorrect or unclear decimal point
placement
15
Confusion between Look-alike,
sound-alike drug names
Tall Man lettering may assist in reducing look-alike
errors
16
Case 2: Look-alike sound-alike drug
names
A patient was prescribed morphine 5mg
subcutaneously. The administering nurses
erroneously selected and administered
HYDROmorphone 5mg.
This was equivalent to a dose of 25-35mg
morphine.
The outcome was fatal for this patient.
17
When administering HYDROmorphone
Use a second person check when witnessing and checking
HYDROmorphone
(NSW Health, 2013).
The second person is responsible for:
 confirming the identity of the patient
 confirming the selection of the correct medication confirming
that the dose and calculations are correct
 for an infusion, confirming that the infusion pump or syringe
driver has been correctly set
 countersigning the administration on the medication chart
against that of the administering person (NSW Health, 2013)
18
To minimise the risk of error:
•
Separate from morphine and oxycodone in Schedule 8
medication storage unit
•
Consider recording HYDROmorphone in a separate
Schedule 8 Drug Register
•
Return unnecessary HYDROmorphone to the pharmacy
department
•
Don’t stock high-potency HYDROmorphone in ward
areas unless there is a clinical need
19
To minimise the risk of error:
• Use opioid dose calculator tools for dose
adjustment
• Prioritise medication reconciliation and pharmacy
review
• Use Tall Man lettering to reduce risk of confusion
with morphine e.g. HYDROmorphone
20
The key messages:
• HYDROmorphone is NOT morphine
• HYDROmorphone is 5 – 7 times STRONGER than
morphine
• HYDROmorphone is available in a variety of formulations
and strengths
• HYDROmorphone errors may result in serious adverse
patient outcomes
21
References and resources
Australian Commission on Safety and Quality in Healthcare. National Tall Man Lettering 2014; Available from:
http://www.safetyandquality.gov.au/our-work/medication-safety/safer-naming-labelling-and-packaging-of-medicines/nationaltall-man-lettering/.
MIMS Australia (2015) https://www.mimsonline.com.au.acs.hcn.com.au
NSW Clinical Excellence Commission. Medication Safety and Quality Program. Tall Man Lettering
http://www.cec.health.nsw.gov.au/programs/medication-safety/tall-man-lettering#navigation
NSW Clinical Excellence Commission. Patient Safety. Clinical incident management in the NSW Public Health system.
http://www.cec.health.nsw.gov.au/clinical-incident-management (accessed February 2016)
NSW Ministry of Health HYDROmorphone: High-risk analgesic. Safety Alert number 004/11
http://www.health.nsw.gov.au/sabs/Pages/default.aspx
NSW Ministry of Health. (2015) High-Risk Medicines Management.
http://www0.health.nsw.gov.au/policies/pd/2015/PD2015_029.html
NSW Ministry of Health. (2013) Medication Handling in NSW Public Health Facilities
http://www.health.nsw.gov.au/pharmaceutical/Pages/medication-handling-pubhealth.aspx.
NSW Ministry of Health Medication Incidents Involving HYDROmorphone (Opioid). Safety Notice 011/10
http://www.health.nsw.gov.au/sabs/Pages/default.aspx
22
Thank you
Questions
For further information:
[email protected]
www.cec.health.nsw.gov.au
23