Dialogue Volume 14 Issue 1 2018 - Page 45

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 45