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Medication Safety At The Bedside HYDROmorphone vs. Morphine
Presented By: Gariné Jamjekian Date: March 1st, 2013
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• Overview • HYDROmorphone vs. Morphine • Documentary • Safety Initiatives • Resources • Key Messages
Outline
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• To better understand the meaning of “medication safety” and “medication incident”
• To develop a strong understanding of the
differences between HYDROmorphone and morphine
• To be aware of the safety initiatives set in
place to reduce preventable medication errors
Learning Objectives
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• Medication Safety
–Freedom from preventable harm with medication use
Overview
ISMP Canada. Definition of terms. http://www.ismp-canada.org/definitions.htm Accessed February 15, 2013. ISMP Canada Safe Medications Use, Mistakes with medicines can happen. Are they preventable? November 1, 2012 presentation. Available at: http://www.safemedicationuse.ca/tools_resources/tips.html. Accessed February 15, 2012
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• Medication Incident = Medication Error
–A mistake with a medicine or a problem that could cause a mistake with a medicine
Overview
ISMP Canada. Definition of terms. http://www.ismp-canada.org/definitions.htm Accessed February 15, 2013. ISMP Canada Safe Medications Use, Mistakes with medicines can happen. Are they preventable? November 1, 2012 presentation. Available at: http://www.safemedicationuse.ca/tools_resources/tips.html. Accessed February 15, 2012
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Medication Incident
HEALTH CARE PROFESSIONAL
PATIENT
PRESCRIBING
SYSTEMS
PROFESSIONAL PRACTICE
COMMUNICATION LABEL AND PACKAGE
DRUG NAME
ADMINISTRATION DISPENSING
ISMP Canada. Definition of terms. http://www.ismp-canada.org/definitions.htm Accessed February 15, 2013. ISMP Canada Safe Medications Use, Mistakes with medicines can happen. Are they preventable? November 1, 2012 presentation. Available at: http://www.safemedicationuse.ca/tools_resources/tips.html. Accessed February 15, 2012
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Medication Incident
HEALTH CARE PROFESSIONAL
PATIENT
PRESCRIBING
SYSTEMS
PROFESSIONAL PRACTICE
COMMUNICATION LABEL AND PACKAGE
DRUG NAME
ADMINISTRATION DISPENSING
ISMP Canada. Definition of terms. http://www.ismp-canada.org/definitions.htm Accessed February 15, 2013. ISMP Canada Safe Medications Use, Mistakes with medicines can happen. Are they preventable? November 1, 2012 presentation. Available at: http://www.safemedicationuse.ca/tools_resources/tips.html. Accessed February 15, 2012
PREVENTABLE
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• Physician ordering • Order entry and transcription • Dispensing and delivery • Administration • Monitoring
Stages of Medication Use
Marsham JA, U DK, Lam RWK et al. Medication error events in Ontario acute care hospitals. Can J Hosp Pharm. 2006;59(5):243-50.
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Stages of Medication Use
Marsham JA, U DK, Lam RWK et al. Medication error events in Ontario acute care hospitals. Can J Hosp Pharm. 2006;59(5):243-50.
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Medication Error Types
Marsham JA, U DK, Lam RWK et al. Medication error events in Ontario acute care hospitals. Can J Hosp Pharm. 2006;59(5):243-50.
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Wrong Drug Errors
PA PSRS Patient Saf Advis 2007 Sep;4(3):89.
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HYDROmorphone vs. Morphine
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• Of all the wrong drug safety reports that include morphine and/or HYDROmorphone: – 62% of the time morphine was prescribed but
HYDROmorphone was given in error – 71% of errors occurred when the medications
were selected from unit stock (selection error)
Why Should We Care?
PA PSRS Patient Saf Advis 2007 Sep;4(3):89.
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• True HYDROmorphone/Morphine Event
Documentary: http://youtu.be/J4CZEmvqnw8
Why Should We Care?
ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
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• BOTH are opioid analgesics
• SIMILAR mechanism of action
• SIMILAR side effect profile
• NOT the same drug • NOT equivalent in dosing
HYDROmorphone/Morphine
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Mechanism of Action
Kalant H, Grant DM, Mitchell J. Principles of Medical Pharmacology. 7th Edition. Toronto, Canada. Elsevier; 2007.
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• Nausea and vomiting • Drowsiness/sedation • Constipation • Respiratory depression (rare) • Cardiac depression/arrest (rare) • Tolerance/dependence
Adverse Effects
DiPiro JT, Talbert RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach. 7th Ed. Chapter 62: Pain Management. New York. McGraw-Hill Companies; 2008.
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HYDROmorphone : morphine
What Is The Difference?
PA PSRS Patient Saf Advis 2007 Sep;4(3):89. ISMP Canada Safety Bulletin. Identifying knowledge deficits related to HYDROmorphone. June 27, 2012. Available at: http://www.ismp-canada.org/download/safetyBulletins/2012/ISMPCSB2012-07_IdentifyingKnowledgeDeficits-HYDROmorphone.pdf. Accessed February 18, 2013.
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HYDROmorphone : morphine
5:1
HYDROmoprhone is 5 times* more potent than morphine
*4 to 7 depending on source
What Is The Difference?
PA PSRS Patient Saf Advis 2007 Sep;4(3):89. ISMP Canada Safety Bulletin. Identifying knowledge deficits related to HYDROmorphone. June 27, 2012. Available at: http://www.ismp-canada.org/download/safetyBulletins/2012/ISMPCSB2012-07_IdentifyingKnowledgeDeficits-HYDROmorphone.pdf. Accessed February 18, 2013.
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Morphine
HYDROmorphone
2 to 4 mg IV/SC q2h PRN pain
0.4 to 0.8 mg IV q2h PRN pain
30 mg PO q4h PRN pain
6 mg PO q4h PRN pain
2.5 mg PO q4h PRN pain
0.5 mg PO q4h PRN pain
Examples
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Other Differences
HYDROmorphone Morphine Better oral absorption Lower oral absorption
Eliminated in urine 90% eliminated in urine, 10% in feces
No major active metabolites Active metabolites formed (toxicity in renal impairment)
Less itchiness (less histamine release)
More itchiness (more histamine release)
Higher potential for addiction
HYDROmorphone. LexiComp Online. Available at: http://www.lexicomp.com. Accessed February 15, 2013. Morphine. LexiComp Online. Available at: http://www.lexicomp.com. Accessed February 15, 2013.
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Memory Aid
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Memory Aid
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Memory Aid
Horse HYDROmorphone
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Memory Aid
Horse HYDROmorphone
Mouse morphine
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Memory Aid
Horse HYDROmorphone
Mouse morphine
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HYDROmorphone/Morphine Event Analysis
ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
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HYDROmorphone/Morphine Event Analysis
ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
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HYDROmorphone/Morphine Event Analysis
Incomplete communication
Selection of wrong drug
Interruptions
No process for verification
ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
“Morph 10 mg IM”
Look-alike sound-alike drugs
Narcotic cupboard organization
Patient and family unaware
Side effect not recognized
PATIENT HARM: FATAL
INCIDENT
Patient discharged, no monitoring
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Safety Initiatives
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1. Limiting access and reducing options 2. Reorganization of narcotic cupboard 3. Reduce “look-alike” potential (TALLman) 4. Employ technology
Safety Initiatives
PA PSRS Patient Saf Advis 2007 Sep;4(3):89. ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
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5. Independent double-check policies prior to administration
6. Monitor patients
7. Potency education for staff
8. Educate patients
Safety Initiatives
PA PSRS Patient Saf Advis 2007 Sep;4(3):89. ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
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Safety Initiatives
BEFORE AFTER
PA PSRS Patient Saf Advis 2007 Sep;4(3):89. ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
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• Pharmacist – medication experts • Interprofessional team members • Hospital standards of care, policies and
procedures • ISMP Canada www.ismp-canada.org
Resources
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Website: www.medsafety.weebly.com *Self Assessment Quiz for all nurses
Resources
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• HYDROmorphone and morphine – Similar mechanism of action, side effects – NOT the same drug, NOT equivalent in dosing
HYDROmoprhone is approximately 5 times more potent than morphine!
• Use caution when administering these and other narcotic drugs to patients
Key Messages
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Memory Aid
Horse HYDROmorphone
Mouse morphine
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• DiPiro JT, Talbert RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach. 7th Ed. Chapter 62: Pain Management. New York. McGraw-Hill Companies; 2008.
• HYDROmorphone. LexiComp Online. Available at: http://www.lexicomp.com. Accessed February 15, 2013.
• ISMP Canada. Definition of terms. http://www.ismp-canada.org/definitions.htm Accessed February 15, 2013.
• ISMP Canada. Event analysis report: hydromorphone/morphine event XXX Hospital, XXX, XXX. Available at: http://www.ismp-canada.org/download/Hydromorphone_Morphine_RCA_Report_final12.pdf. Accessed January 25, 2013.
• ISMP Canada Safety Bulletin. Identifying knowledge deficits related to HYDROmorphone. June 27, 2012. Available at: http://www.ismp-canada.org/download/safetyBulletins/2012/ISMPCSB2012-07_IdentifyingKnowledgeDeficits-HYDROmorphone.pdf. Accessed February 18, 2013.
• ISMP Canada Safe Medications Use, Mistakes with medicines can happen. Are they preventable? November 1, 2012 presentation. Available at: http://www.safemedicationuse.ca/tools_resources/tips.html. Accessed February 15, 2012.
• Kalant H, Grant DM, Mitchell J. Principles of Medical Pharmacology. 7th Edition. Toronto, Canada. Elsevier; 2007.
• Marsham JA, U DK, Lam RWK et al. Medication error events in Ontario acute care hospitals. Can J Hosp Pharm. 2006;59(5):243-50.
• Morphine. LexiComp Online. Available at: http://www.lexicomp.com. Accessed February 15, 2013. • PA PSRS Patient Saf Advis 2007 Sep;4(3):89.
References