practice partner
woman ’ s potassium was significantly elevated and that Kayexalate was administered and spironolactone was discontinued . There was no evidence that an electrocardiogram was ordered or that a physician assessed the woman . There was a nursing note indicating that “ the resident had significant abnormality in the lab results , especially elevated K and CBC . Resident is on Kayexalate . Fax the results to [ hospital ] ER MD on call for further evaluation .” The advice given was for the facility ’ s physician to review the results on July 2 , 2014 . That same day , there was documentation that the woman had been complaining of severe back pain and was continuing to be administered as needed hydromorphone . On June 29 , 2014 , nursing notes indicated that the woman was receiving 1 mg of hydromorphone for pain on an as needed basis as well as hydromorphone 3 mg every 24 hours for breakthrough pain . The physician in the emergency department was again contacted and narcotic medications were changed to Hydromorph Contin 12 mg twice a day , along with hydromorphone for breakthrough pain . On July 1 , 2014 , the woman was unresponsive to verbal stimulation and was not responding to a tap on shoulder , sternal rub or verbal command . Her skin was clammy and she was slightly pale . Vital signs were : BP 83 / 55 , pulse 97 , respiratory rate 9 with 15 seconds of apnea and 02 saturation of 84 % on room air . The woman was transported to hospital . Upon review of the records , it could not be determined if the patient had actually been seen by a physician from the time of her admission to the LTCH on June 25 , 2014 , until her transfer to hospital due to unresponsiveness on July 1 , 2014 . The hospital admission note of July 1 , 2014 , completed by the admitting physician ( who was also the physician who adjusted the medication dose ), indicated “ this resulted in a significant narcotic overdose that culminated today with a period of unresponsiveness .” While in the emergency department , the woman was treated with two doses of naloxone with some spontaneous improvement . It was also noted that she had not been receiving her lactulose while in the LTCH . The woman remained unresponsive in the hospital and the decision was made to deem her palliative and transfer her back to the LTCH . The woman subsequently died on July 3 , 2014 .
Discussion From the records provided for review , it was difficult to determine the morphine equivalent dose prior to the change to long-acting hydromorphone . It would appear that the dose of narcotic was doubled and that the long-acting hydromorphone was likely crushed and put into applesauce . If , in fact , the hydromorphone was crushed and then put in applesauce , it was contrary to the product monograph which states :
“ HYDROMORPH CONTIN capsules should not be broken , chewed , dissolved or crushed , due to the risk of fatal HYDROmorphone overdose .
HYDROMORPH CONTIN should be swallowed whole or opened and the contents sprinkled onto a tablespoonful of warm or cold ( 4-40 º C ) applesauce or room temperature custard . The entire contents of the tablespoon of food and HYDROmorphone mixture should be swallowed as soon as possible after sprinkling and should be discarded if not consumed . The food / drug mixture should not be chewed , and the ingestion should be followed by rinsing the mouth with fluids to ensure that the entire contents are swallowed .”
It appears that there was an error in the calculation of the daily morphine equivalent dose when converting the woman from the short-acting hydromorphone to the long-acting hydromorphone . The Committee also noted the lack of communication between the nursing home staff and attending physicians in the emergency department . The absence of the medical director compounded this problem and the lack of physician attendance to the patient while in the LTCH likely had an impact on the care provided . The Committee recommended that the long-term care home involved review the circumstances of this case with particular attention to improved communication and pain assessments by the nursing staff and improved communication between the attending physicians and the nursing staff , especially when prescribing opioids . MD
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Dialogue Issue 2 , 2017