1. Safe use of HYDROmorphone
CLINICAL EXCELLENCE COMMISSION
Medication Safety and Quality Unit
February 2016

2. Session Objectives: The objectives of this presentation are to:
Provide a brief overview of HYDROmorphone formulations available
Describe recognised risks associated with HYDROmorphone storage and handling
Discuss strategies to address risks

3. What is HYDROmorphone:
It is a potent opioid analgesic
It is used to manage moderate to severe acute or chronic pain
It is 5 – 7 times STRONGER than morphine
HYDROmorphone is NOT morphine
Errors involving its use can result in fatal over-dose

4. HYDROmorphone formulations
HYDROmorphone is manufactured in a variety of oral and injectable formulations
Oral formulations include:
tablets – variety of strengths, including immediate release and modified release
oral liquid
Injectable formulations include:
2mg/ml and 10mg/ml (high potency)

5. HYDROmorphone overdose symptoms
respiratory depression
extreme drowsiness
cold and/ or clammy skin
pupillary constriction
bradycardia and hypotension (MIMS Australia, 2015)

6. HYDROmorphone incidents
Fatal and near fatal overdose incidents have been reported within Australia and internationally
In 2013 HYDROmorphone was the 15th most frequently reported medicine in clinical incidents in NSW (NSW Clinical Excellence Commission, 2014)

7. Errors associated with HYDROmorphone use have arisen from:
Complexity of branded products leading to incorrect product selection
Use of fractional doses
Confusion between look-alike, sound-alike names of HYDROmorphone and morphine

8. Complexity of branded products
Hydromorphone is available in multiple strengths and dose forms:
Immediate release tablets
Immediate release oral liquid 1mg/ml
Controlled-release tablets
Injectable - immediate release and high- potency

9. Immediate release tablets
Dilaudid® tablets
Available in 2mg, 4mg, 8mg strengths
May be given several times a day

10. Immediate release oral liquid
Dilaudid® oral liquid 1mg/ml
May be given several times a day

11. Controlled release tablets
Jurnista® controlled release tablets
Available in 4mg, 8mg, 16mg, 32mg, 64mg strengths
Only given once a day

12. Injectable formulations
Injectable Dilaudid® 2mg/ml Available as 1mL ampoules

13. High-potency injectable
Injectable Dilaudid® – HP high-potency 10mg/ml Available as 1mL, 5mL and 50mL ampoules

14. Case 1: Complexity of branded products
A patient was prescribed oral HYDROmorphone 4mg modified release once a day. The nurse erroneously administered 4mg of an immediate release HYDROmorphone formula. Fortunately there was no adverse outcome for the patient.
Extreme care needs to be taken during product selection. Errors have occurred when modified release tablets have been selected instead of immediate release and vice versa. This type of error is not uncommon.
In addition to prescribing using the generic name, facilities may encourage the use of the brand name to define HYDROmorphone products.

15. Use of fractional doses
Fractional doses may be necessary due to the high potency of HYDROmorphone e.g. HYDROmorphone 0.25mg
They can lead to errors associated with incorrect or unclear decimal point placement

16. Confusion between Look-alike, sound-alike drug names
Tall Man lettering may assist in reducing look-alike errors

17. Case 2: Look-alike sound-alike drug names
A patient was prescribed morphine 5mg subcutaneously. The administering nurses erroneously selected and administered HYDROmorphone 5mg. This was equivalent to a dose of 25-35mg morphine. The outcome was fatal for this patient.
Incidents have occurred when the similarity in drug name has led nurses to believe that HYDROmorphone was in fact morphine. Storing HYDROmorphone separately from morphine in the S8 drug storage unit will provide another barrier to incorrect product selection.

18. When administering HYDROmorphone
Use a second person check when witnessing and checking HYDROmorphone (NSW Health, 2013).
The second person is responsible for:
confirming the identity of the patient
confirming the selection of the correct medication confirming that the dose and calculations are correct
for an infusion, confirming that the infusion pump or syringe driver has been correctly set
countersigning the administration on the medication chart against that of the administering person (NSW Health, 2013)
The presenter should describe medication reconciliation and pharmacy review processes in their facility. The presenter should describe additional safety mechanisms in place, for example additional labelling using tall man lettering – HYDROmorphone.

19. To minimise the risk of error:
Separate from morphine and oxycodone in Schedule 8 medication storage unit
Consider recording HYDROmorphone in a separate Schedule 8 Drug Register
Return unnecessary HYDROmorphone to the pharmacy department
Don’t stock high-potency HYDROmorphone in ward areas unless there is a clinical need
Return HYDROmorphone to pharmacy departments – The presenter should describe facility policy and procedures for returning unnecessary HYDROmorphone stock to pharmacy department.
Separate from morphine in Schedule 8 medication storage unit. The presenter should describe policy and procedures for separating HYDROmorphone from other medicines in the S8 drug cabinet in their facility.
The presenter should describe additional safety mechanisms in place, for example additional labelling using tall man lettering – HYDROmorphone.

20. To minimise the risk of error:
Use opioid dose calculator tools for dose adjustment
Prioritise medication reconciliation and pharmacy review
Use Tall Man lettering to reduce risk of confusion with morphine e.g. HYDROmorphone
The presenter should describe medication reconciliation and pharmacy review processes in their facility. The presenter should describe additional safety mechanisms in place, for example shelf-labelling or additional product labelling using tall man lettering – HYDROmorphone.

21. The key messages: HYDROmorphone is NOT morphine
HYDROmorphone is 5 – 7 times STRONGER than morphine
HYDROmorphone is available in a variety of formulations and strengths
HYDROmorphone errors may result in serious adverse patient outcomes

22. References and resources
Australian Commission on Safety and Quality in Healthcare. National Tall Man Lettering 2014; Available from: tall-man-lettering/. MIMS Australia (2015) NSW Clinical Excellence Commission. Medication Safety and Quality Program. Tall Man Lettering NSW Clinical Excellence Commission. Patient Safety. Clinical incident management in the NSW Public Health system. (accessed February 2016) NSW Ministry of Health HYDROmorphone: High-risk analgesic. Safety Alert number 004/11 NSW Ministry of Health. (2015) High-Risk Medicines Management. NSW Ministry of Health. (2013) Medication Handling in NSW Public Health Facilities NSW Ministry of Health Medication Incidents Involving HYDROmorphone (Opioid). Safety Notice 011/10

23. Thank you Questions
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