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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
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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
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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)
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HYDROmorphone overdose
symptoms
• respiratory depression
• extreme drowsiness
• cold and/ or clammy skin
• pupillary constriction
• bradycardia and hypotension
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(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)
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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
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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
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Immediate release tablets
Dilaudid® tablets
• Available in 2mg, 4mg, 8mg strengths
• May be given several times a day
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Immediate release oral liquid
Dilaudid® oral liquid 1mg/ml
• May be given several times a day
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Controlled release tablets
Jurnista® controlled release tablets
• Available in 4mg, 8mg, 16mg, 32mg, 64mg strengths
• Only given once a day
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Injectable formulations
Injectable Dilaudid® 2mg/ml
Available as 1mL ampoules
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High-potency injectable
Injectable Dilaudid® – HP high-potency 10mg/ml
Available as 1mL, 5mL and 50mL ampoules
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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.
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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
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Confusion between Look-alike,
sound-alike drug names
Tall Man lettering may assist in reducing look-alike
errors
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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.
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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)
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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
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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
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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
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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
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Thank you
Questions
For further information:
[email protected]
www.cec.health.nsw.gov.au
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