combined effects of an overdose of hydromorphone and complications of pneumonia (following treatment for chronic clostridium difficile colitis) against a background of heart disease and lung disease
AI-generated summary
An 88-year-old woman with chronic lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distress on 24 October 2013. Two nurses unfamiliar with hydromorphone administered a 10-fold overdose (5 mg instead of 0.5 mg), mistaking the dose unit from milligrams to millilitres and confusing it with morphine. The patient rapidly lost consciousness and died hours later. Contributing factors included inadequate communication with family, lack of staff familiarity with the drug, absence of visual warnings distinguishing hydromorphone from morphine and high-potency versions, and delayed recognition of overdose signs by nursing staff. The coroner found the overdose contributed to death alongside pneumonia and underlying cardiopulmonary disease.
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Specialties
cardiologyrespiratory medicineintensive caregastroenterologypalliative care
medication error: tenfold overdose of hydromorphone due to confusion of dosing units (milligrams vs millilitres)
staff unfamiliarity with hydromorphone pharmacology and dosing
lack of visual distinction between hydromorphone and morphine ampoules
lack of visual distinction between different concentration strengths of hydromorphone
inadequate pharmacy guidance to nursing staff about drug potency differences
inadequate post-injection monitoring and failure to recognise overdose signs promptly
poor communication between medical staff and family regarding clinical deterioration and pain management
lack of formal palliative care planning despite clinical decline
previous day's medication error (morphine given instead of hydromorphone) indicating systemic confusion
Coroner's recommendations
NSW Department of Health should conduct an audit of its High Risk Medicines Management Policy to ascertain what practices and procedures have been implemented by Local Drug and Therapeutic Committees regarding hydromorphone (part 3.2)
NSW Department of Health should strengthen its High Risk Medicines Management Policy in relation to hydromorphone and mandate that the drug must be referred to as HYDROmorphine Dilaudid or Dilaudid (not merely 'should') by all hospital staff including prescribers, nurses and pharmacists
NSW Department of Health should issue another Safety Notice (in addition to SA 004/11) reinforcing to all staff the potential confusions between morphine and hydromorphone and the confusions resulting from differing concentrations of the drugs, with a mandated education component
NSW Department of Health should investigate options available through the Therapeutic Goods Administration (TGA) for restricting the use of different sized/coloured ampoules and/or bottles to minimise confusion between lower and higher potency strengths of hydromorphone
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