Safety Initiatives
Over the years, many reports have been made to ISMP Canada regarding the confusion between HYDROmorphone and morphine. The mix-up between these two drugs is the most common and serious error that can occur between two high-alert drugs. The risk of mixing up these two drugs exists in almost every acute care facility where these drugs are used and serious errors, which may be fatal, can occur at any time. Below is a discussion of safety initiatives that have been implemented in health care facilities to reduce the risk of patient harm due to the mix-up between HYDROmorphone and morphine.
- Limiting Access
Hospitals are making efforts to reduce the amount of HYDROmorphone in an attempt to eliminate this drug from floor stock when possible. This is especially important when usage of HYDROmorphone on a unit is low, and the availability of it in floor stock may pose a risk of accidentally using the medication. For these reasons, most units have removed all HYDROmorphone from floor stock and if the drug is needed, only the 2mg/mL strength is stocked for the unit. On palliative care units, the 10mg/mL strength may be used more frequently and may be more readily available as floor stock. For all other units within a given hospital, the 10 mg/mL HYDROmorphone vials/ampules/prefilled syringes will not be stocked on the floor. Should a patient specific need for HYDROmorphone 10 mg/ml be required, the pharmacy department will ensure that a sufficient patient specific supply is sent up to the floor. Additionally, drug use evaluations are constantly being performed by the pharmacy department to monitor the usage of these drugs. If it is noted that these drugs are not being used in a given patient care unit, they will be removed from floor stock from that particular unit. - Reducing Options
When both HYDROmorphone and morphine need to be stocked on a patient care unit at the same time, all efforts are being made to reduce options such that morphine and HYDROmorphone will not be stocked in the same strengths or same dosage forms (vials, ampules, etc). Pre-filled syringes of narcotics in commonly used clinical doses are not available in Canada and therefore purchasing options are limited. The pharmacy department is working hard to ensure purchases made of HYDROmorphone and morphine products appear as different as possible from each other, taking into consideration what the medication is stored in (vial or ampule), the colour of the storage unit and the label on the package that the medications come in. - Reorganization of the Narcotic Cupboard
Most hospitals have established a Narcotics Safety Group which works to implement changes within the hospital to ensure the safe use of narcotic (opioid) analgesics. In particular, this group has worked to reorganize the narcotic cupboard in order to physically separate the locations of HYDROmorphone and morphine in the cupboard. If these two drugs are not kept in close proximity of one another, we can prevent drug selection errors. - Reducing "Look-Alike" Potential
ISMP Canada recommends the use of TALLman lettering to emphasize the word "HYDRO" in HYDROmorphone on all pharmacy labels, medication administration records, narcotic record sheets, medication bin labels, computer screens and all other places that the drug name may appear. The capitalization of the beginning part of HYDROmorphone significantly differentiates it from the drug name morphine and reduces the look-alike potential. In addition to applying TALLman lettering to these two drugs, recommendations have been made to use the brand names as a confirmation that the correct drug is being selected. For example, one of HYDROmorphone's brand names is Dilaudid, and one of morphine's brand names is Kadian. The indication of the brand name equivalent can help prevent confusion, and can also be a double check point for health care professionals. - Employing Technology
The implementation of technological solutions such as bar coding and automated dispensing technology are long term projects that many hospitals are undertaking. The use of technology may reduce the risk of mix-ups between HYDROmorphone and morphine but are not a means of elimination of this risk. Health care professionals should not depend on technological solutions and should always be alert of the potential for errors regardless of technology. For example, if HYDROmorphone is stocked in error instead of morphine in the morphine bin of an automated dispensing machine, the error of administering HYDROmorphone instead of morphine can still occur, despite the selection of morphine from the machine (i.e. if one does not recognize that the incorrect drug was stocked in the machine). - Performing Independent Double-Checks
Prior to the administration of IV narcotic medications (opioids), an independent double-check of the narcotic dose should be required. Most hospitals have developed standards of practice and policies in order to ensure that independent double-checks are performed. This action ensures redundancies and may be an additional step where errors may be recognized, especially when nurses obtain medications from floor stock. An independent double-check is a process in which a second health care provider (nurse, pharmacist, etc) verifies the dose of the medication independently from the primary health care provider who selected the medication. In order to maximize the independence of the double-check, the first practitioner should not communicate what he or she expects the second practitioner to see during the check. - Patient Monitoring
Most hospitals have implemented policies that specify the type of monitoring that should be performed after the administration of parenteral narcotic medication. The policies typically define the frequency and duration of monitoring that should occur before a patient is allowed to be discharged from the facility. - Potency Education for Staff
ISMP Canada encourages education of staff through the provision of safety information on the use of potent opioid analgesics. You may see this through the form of newsletters, inservices or external events. Additionally, you may find posters regarding HYDROmorphone and morphine posted near the narcotic cupboard which you may use as a reference when required. - Education of Patients
Patients should be educated on the medications that they are about to receive. Prior to administration of any narcotic medications, the health care practitioner should repeat the name of the medication out load to the patient as another source of confirmation. Many hospitals have developed medication policies that require nurses to describe each medication (name, dose, route, frequency) prior to administration of the medication to ensure patients are aware of what medication they are about to receive.
1. ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX.
Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
2. ISMP Canada Safety Bulletin. An omnipresent risk of morphine-hydromorphone mix-ups. JUne 2004. Available at: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2004-06.pdf. Accessed January 25, 2013.
3. PA PSRS Patient Saf Advis 2007 Sep;4(3):89.