PRACTICE PARTNER
PATIENT SAFETY
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
Limit the
dispensed
amount of
opioids
P
The availability of
a large quantity of
hydromorphone
in the patient’s
home presented a
substantial safety risk
rescribers are re-
minded to limit the
dispensed amount
of opioid doses to
reduce the potential for acciden-
tal or intentional misuse by both
patients and those with access to
the medications.
The reminder was prompted
by a review into the death of a
45-year-old woman who died from
hydromorphone intoxication after
intentional ingestion of more than
100 capsules of her husband’s con-
trolled release hydromorphone. The
review was conducted by an expert
review committee from the Office
of the Chief Coroner.
The patient was admitted to hos-
pital approximately 2-3 hours after
ingesting between 100-160 capsules
of her husband’s hydromorphone
CR 6 mg. The exact number of
pills ingested could not be
determined as the patient’s
husband was unsure as to
how many of the 160 capsules
dispensed five days earlier had
already been taken by him. Had
the capsules been taken twice daily,
there would have been approxi-
mately 150 capsules left, represent-
ing 900 mg of hydromorphone
ingested.
The woman had a medical his-
tory of depression and an anxiety
disorder with at least two prior
admissions to hospital. Her pre-
scribed medications prior to
admission were: domperidone 10
mg (by mouth three times a day),
trazodone 100 mg (by mouth every
night at bed time), risperidone 0.5
mg (every night at bed time) and
clonazepam 2 mg (by mouth three
times a day).
ISSUE 1, 2018 DIALOGUE
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