PRACTICE PARTNER
“It is difficult to assess whether this death was entirely preventable; however there do appear to be
instances where appropriate interventions may have altered the outcome,” stated the Committee’s report.
These include:
T
he restriction of access to a large and lethal amount of hydromorphone in the patient’s home may have
prevented ingestion
larification of the formulation of ingested medication (long-acting versus immediate release) may have better
C
guided detoxification efforts
O
bservations of lethargy, combined with complaints of dizziness and need for assistance to the bathroom
should have prompted questions about possible lingering effects of the hydromorphone overdose and