Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

ABSTRACT:

Background

Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies.

Methods

In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented.

Results

We identified 8 cases involving decedents aged 19 to 91 years. The cases involved

SUBMITTER: Lowe A 

PROVIDER: S-EPMC5378545 | biostudies-literature | 2017 Jan-Mar

REPOSITORIES: biostudies-literature