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Patient Safety Tip
of the Week
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:
- Education of physicians, nurses,
pharmacists, etc. on the different potencies of various opioids (but keep
in mind that education and training are relatively weak patient safety
interventions so other preventive interventions will be needed)
- Equipotency cards/posters/popups for
commonly prescribed opioids
- Consider restricting ordering of
HYDROmorphone to clinicians who you have specifically credentialed and
privileged to order and administer HYDROmorphone (such as Pain Management
physicians)
- Consider dose range alerts during CPOE
(eg. note a typical dose is 0.2-0.5 mg. IV and limit dose to 1.0 mg for an
opioid-naïve patient)
- Don’t allow orders for dose ranges (eg.
do not allow “Dilaudid 2-4 mg q3h prn for pain levels…”)
- Other alerts during CPOE (eg. if a
patient is already on a sedative/hypnotic drug prompt “Are you aware
sedative agents make patient more vulnerable to opioid-induced respiratory
depression?”)
- Include a “hard stop” if an attempt is
made to order one opioid in a patient already receiving another opioid
- Other decision support tools for
ordering (eg. prompts asking about whether the patient is opioid-naïve or
opioid-tolerant, then suggest starting dosages)
- Establish criteria for using intravenous
opioids
- Patient selection/identify hi risk
patients (the very young and the very old, those with obesity, sleep
apnea, neuromuscular diseases, COPD, and those in higher ASA classes,
those receiving sedative/hypnotic drugs)
- Screening for obstructive sleep apnea
(OSA) prior to use of IV opioids with a tool such as STOP or STOP-Bang
- Look for other risk factors (renal
function, coadministration of sedative/hypnotic drugs, etc.)
- Monitor, monitor, monitor…
- Continuous pulse oximetry and
capnography or apnea monitoring
- Close monitoring (in an ICU setting if
necessary for high-risk patients)
- Pain assessment, RASS (Richmond
Agitation-Sedation Scale) or POSS (Pasero Opioid-Induced Sedation Scale)
or other scale for level of arousal other scale for level of arousal
- Enforce RASS or POSS (by requiring input
of RASS or POSS score at BMV or when taking out of ADC)
- Tie recommended course of action to the
RASS or POSS score
- Include section of opioids on your
“Ticket to Ride” intrahospital transfer form for patients being taken to
areas such as Radiology
- Always have narcotic reversal agents
readily available where IV opioids are being used and have protocols that
deal with issues like renarcotization
- Standardized order sets
- Different order sets for opioid-naïve
and opioid-tolerant patients
- Avoid order sets that allow a provider
to check boxes for contraindicated combinations such as IV morphine and
epidural HYDROmorphone/bupivacaine on the same order set
- Avoid basal rates for PCA in
opioid-naïve patients
- Warnings when taking it out of ADC (eg.
“This is DILAUDID. Is this what you wanted?”) or require a witness for
overrides when using ADC or eliminate overrides completely for HYDROmorphone
- Independent double checks
- Use tall man lettering “HYDROmorphone”
- Consider limiting the number of
different opioids you use for acute pain management (eg. use morphine as
your “preferred” opioid and reserve
Dilaudid for rare patient who gets pruiritis from morphine though even
that is challenged by the meta-analysis showing no difference in pruritis
between Dilaudid and morphine)
- Have pharmacists prepare and dispense
the doses in prefilled unit dose syringes
- Stock HYDROmorphone only in lower doses
on patient care floors and ADC’s
- Stock HYDROmorphone and morphine in
different concentrations and keep them separate in stock
- Add labels to avoid confusion (consider
using brand name “HYDROmorphone (DILAUDID)”)
- Involve patients and families in
educational efforts about IV opioid therapy
- Perform regular audits with feedback for
doses of HYDROmorphone exceeding 1 mg
- Make sure HYDROmorphone is on your
“High-Alert” drug list
- Consider doing a FMEA (Failure Mode and
Effects Analysis) to determine your potential vulnerabilities to Dilaudid
incidents
Our prior columns on patient safety issues
related to Dilaudid/HYDROmorphone:
References:
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
https://www.ismp-canada.org/download/safetyBulletins/2020/ISMPCSB2020-i11-Medications-Reported-Harm.pdf
(ISMP Canaada 2020)
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