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Patient Safety Tip of the Week

January 5, 2021

Dilaudid/HYDROmorphone Still Problematic



One of our most favorite patient safety targets over the years has been misuse of Dilaudid/HYDROmorphone. We were actually a bit surprised that it has been over 3 years since our last column on this issue.


But the problem has not gone away. ISMP Canada recently published its compilation of medications most frequently reported in harm incidents over the past 5 years (ISMP Canaada 2020). They categorized the involved medications by health care setting (hospital, long-term care, community pharmacy, and home and community care).


Two medications appear in the top 3 in multiple settings. HYDROmorphone was in the top 3 in all except community pharmacy. Insulin was the other medication in the top 3 (appearing in 2 institutional care settings). Notably, each of these 2 medications was cited twice as often as any other medication in harm incidents from all health care settings combined.


Moreover, HYDROmorphone was the medication named most often in reports with severe harm or death. It accounted for 11.1% of severe harm or death reports, almost double the next most frequent offender.


We hope you will go back to our previous columns on Dilaudid/HYDROmorphone (listed below). It’s especially worth reiterating some strategies from our June 20, 2017 Patient Safety Tip of the Week  Dilaudid Dangers #4” that you should consider to reduce the risk of Dilaudid/HYDROmorphone (and other opioid) adverse events:



Our prior columns on patient safety issues related to Dilaudid/HYDROmorphone:







ISMP Canaada. Medications Most Frequently Reported in Harm Incidents over the Past 5 Years (2015–2020). ISMP Canada Safety Bulletin 2020; 20(11): 1-5

(ISMP Canaada 2020)





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