MIMS:"hydromorphone causes fatality"

Nurses Medications

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  1. What drug info resources are best for patient safety during drug round

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In Sydney, a hydromorphone mixup with morphine caused a patient's death in 2013.

The coroner's report just was published.

Audrey McGregor inquest: 'Substantial overdose' given by confused nurses, coroner says - ABC News (Australian Broadcasting Corporation)

Mitigating factors were present but definitely there was educational and procedural failure,

which the hospital has tried to rectify since. One nurse continues to work in the same hospital but the other is no longer doing nursing.

I checked my MIMs smartphone app. for hydromorphone. The Australian version has this warning for Dilaudid injection

"This product may cause drowsiness".

Reading down. There is no mention of potential fatality.

I downloaded Davis Drug Guide for 1 month free trial. I checked hydromorphone

"HYDROmorphone. HIGH ALERT"

Reading down

"High alert: Do not confuse with morphine. Fatalities have occurred."

The nurses in this tragedy may or may not have checked MIMS,

but today thousands of nurses will have checked MIMS about drug info. in Australia

MIMS is really light on safety warnings.

The BPharm authors appear to have missed out on a decade of safety awareness.

Unfortunately MIMs is the major and sometimes only drug resource available in med. prep rooms, in Australia.

Perhaps it is time for MIMS to up their game.

As nurses we need the best info that is available for the sake of the patient.

HYDROmorphone does not just cause drowsiness. hydromorphone causes fatality.

Australia needs better than MIMS.

My question..

What drug info resources are commonly available in the USA/Canada?

For hospital nurses doing the medciation round?

Hi,AceofHearts.

True.

"Every nurse should know the difference between morphine, hydromorphone, and fentanyl"

There were some mitigating circumstances, such as the private hospital 'recommending'

palliative care after a harrowing 6 months ordeal, and the registrar prescribing an unfamiliar dose,

etc etc. If you are into tragedies of error the full details.. are here

http://www.coroners.justice.nsw.gov.au/Documents/MACGREGOR_2016_10_26_11_32_04_156.pdf

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The word "assume", is not in my nursing dictionary and for a good reason.

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Specializes in Flight, ER, Transport, ICU/Critical Care.

I cannot get into too many specifics and was not personally involved, but HYDROmorphone "causing a death" secondary to respiratory depression/failure in a hospitalized patient through administration error has happened in the U.S. too.

I can say with the hospital where this sentinel event took place had a major change in how patients were monitored/assessed post administration of this medication.

Bottomline, I think reliance on any single "source" is risky for clinical practice. Before I'd give certain "high risk" medications, I have to know more than a quick monogram and never just depend on "alerts" built into a system. ALERTS just remind me to pause and check myself.

I made it a practice to fully understand the regular medications I encountered and to have access to multiple references for the odd meds. If I didn't understand a med, I didn't give it. I needed to know the basics (indication, metabolism, cautions, precautions, contraindications — relative vs. absolute, mechanism of action and metabolism to the enzyme level if necessary) of my core drug "practice". I recommend that approach to new clinicians.

High Risk Medications (these are mine, other practices will differ!)

Paralytics

Injectible Narcotics — higher the dose, triple or quad check

Insulin

Thrombolytics

Pressors/Catecholamines

Injectible Sedatives/Sedative Infustions

Anesthetic Class Medications

IV K, Mg, Hypertonic NaCl

Anything I find on a patient that I did not "hang".

Good Luck.

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Specializes in PICU, Pediatrics, Trauma.
My job has a micromedex subscription.

But really... do nurses really need the warning that dilaudid can cause death? I don't think a particular facility or a particular drug reference can be blamed here. There has to be some personal responsibility for the nurse who gave the overdose - not just for overdosing the patient, but for failing to monitor the patient afterwards. Narcan works fast. It is very easy to fix an opiate overdose.

...Okay, nevermind - I actually went back and read the article. 0.5mg of dilaudid was 0.05ml. How the heck are you supposed to draw up an amount that small? What are you supposed to do - use a TB syringe, draw up the medication, inject it into a flush, and then inject it into a patient? And who the heck thinks it's a good idea to package dilaudid in a 10mg/1ml vial?

I blame pharmacy/the drug manufacturers at least as much as the nurse in this case. It would be just about impossible to get a medication dose right drawing up that tiny an amount of liquid, so the nurse would be screwed either way.

Can someone in Australia comment whether they have luer lock style syringes that will accurately measure 0.05ml?

This is true. Difficult to accurately draw up 0.05 mls. However, this is often needed in Peds and NICU as most drugs.come in adult dose concentrations.

Also, as others have said, any nurse should know the difference between Dilaudid and Morphine. The problem comes in when a doctor prescribes Dilaudid in an unusual way. In my experience, Dilaudid is usually given in a PCA, or for intermittent doses PRN for either extreme pain not controlled by less potent meds, and/or for those with tollerance. Your average 88 yr old, Opioid naive patient shouldn't need Dilaudid.

This knowledge comes with experience and critical thinking. Not EVERY nurse has this. Doctors should not prescribe Dilaudid in this way as it is dangerous because of potentcy.

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