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Patient Safety Authority Releases Advisory Focusing on Common Causes of Medication Errors
Date:9/27/2007

ore, medication errors sometimes occur when a product is misused."

The Advisory also highlights the increased potential for fatal drug errors to occur between two sound-alike generic drug names: morphine and hydromorphone. Hydromorphone is a common alternative to morphine for treating pain if a patient cannot tolerate morphine; however, hydromorphone is much more potent than morphine.

"One of the most common hospital-based sources of medication errors involving confusion over potency is when a patient is improperly switched from morphine to hydromorphone," said Cohen. "Further, analysis of wrong drug errors submitted to PA-PSRS shows that mix-ups between these two medications outnumber all other pairs of medications."

The potency difference in each is as follows: Oral hydromorphone is approximately four times more potent than oral morphine; injectable hydromorphone is approximately seven times more potent than injectable morphine; and injectable hydromorphone is approximately 20 times more potent than oral morphine.

"In seventy-one percent of the reports we received due to mix-ups between morphine and hydromorphone, the errors occurred when these medications were obtained from unit stock prior to administration," said Cohen. "Facilities must be aware of how they are stocking these look-alike and sound-alike drugs."

Cohen added that further analysis of the wrong drug reports involving either morphine or hydromorphone shows that: 36% involve a mix-up between these two drugs; 62% of the wrong drug reports involving both of these drugs show morphine as the prescribed medication and hydromorphone given in error; the most common care areas where this mix-up occurred were medical/surgical units, medical/oncology units, emergency departments, and telemetry units; and 34% of the reports involve elderly patients (patients 65 years and older).

The Patient Safety Advisory outlines strategies for facilities to avoid mix-ups between morph
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SOURCE Pennsylvania Patient Safety Authority
Copyright©2007 PR Newswire.
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