Patient Safety Topics

Healthcare facilities can strive to identify system-based causes of wrong drug and wrong dose/overdose errors with the use of HYDROmorphone and other opioids. Risk reduction strategies such as constraints and standardization, which focus on system improvement, will be more effective than education alone, which relies on individual performance.

Key Data and Statistics

​Adverse Drug Events with HYDROmorphone

In a 2010 analysis, Authority analysts reviewed 1,694 medication errors reported to the Authority from January 2008 to October 2009 involving the use of HYDROmorphone. Categorization of the reports by harm score found that 68.2% (n = 1,155) of the events reached the patient (harm index = C to I) and 1.8% (n = 30) of the events resulted in patient harm (harm index = E to I). The care areas most often cited in these reports include medical/surgical units (26.5%, n = 449), pharmacy (15.1%, n = 255), and ED (5.8%, n = 99). The majority of the reports, almost 70% (n = 1,179), involved the adult population between the ages of 17 and 64, while 1.7% (n = 28) involved pediatric patients (ages less than 17 years).

The predominant medication error event types associated with HYDROmorphone (see Table 1) were wrong dose/overdosage (16.9%, n = 287), wrong drug (10.9%, n = 185), and monitoring error/documented allergy (8.1%, n = 137).

Table 1. Predominant Medication Error Event Types Associated with the Use of HYDROmorphone (n = 1,135, 67%)

Table. Predominant Medication Error Event Types Associated with the Use of HYDROmorphone (n = 1,135, 67%), January 2008 to October 2009 ​ ​
Event Type Number % of Total Reports (N = 1,694)
Wrong dose/overdosage28716.9%
Wrong drug18510.9
Monitoring error/documented allergy1378.1
Wrong route1317.7
Wrong dose/underdosage1066.3
Other (specify)28917.1

Excerpted from:
Adverse drug events with HYDROmorphone: how preventable are they? Pa Patient Saf Advis 2010 Sep.

Wrong-Drug Errors with HYDROmorphone



  • Oral HYDROmorphone is approximately four times more potent than oral morphine.
    •  For example, 7.5 mg HYDROmorphone per os (PO) = 30 mg morphine PO.
  • Parenteral HYDROmorphone is approximately seven times more potent than parenteral morphine.
    •  For example, 1.5 mg HYDROmorphone intravenous (IV) = 10 mg morphine IV.
  • Parenteral HYDROmorphone is approximately 20 times more potent than oral morphine:
    •  For example, 1.5 mg HYDROmorphone IV = 30 mg morphine PO.

Excerpted from: Inadvertent mix-up of morphine and HYDROmorphone: a potent error. PA PSRS Patient Saf Advis 2007 Sep.

Educational Tools

​Prescribing Considerations
This excerpt from the package inserts for HYDROmorphone is intended to provide information about the appropriate prescribing of HYDROmorphone.

Sample Worksheet
This sample worksheet may be used for documenting facility-specific process and outcome measures involving the use of HYDROmorphone.


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Safety Tips for Patients