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Jennifer Morris and Marie Bismark, MD; September 2016
Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.
Ornstein C. Los Angeles Times. December 5, 2007:B1.
This article discusses one couple's decision to hold a pharmaceutical company legally accountable for package and label designs they believe contributed to the heparin overdose of their twin infants.
Parents sue over babies' heparin overdoses: infants were given too much heparin at Methodist Hospital.
Higgins W. Indianapolis Star. September 13, 2008;News section:A1
Families whose infants died from or were harmed by heparin overdoses are suing the drug manufacturer and the hospital.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Journal Article > Study
Abrecht CR, Brovman EY, Greenberg P, Song E, Rathmell JP, Urman RD. Anesth Analg. 2017;125:1761-1768.
Opioid prescriptions for chronic, noncancer pain have contributed to the national opioid epidemic. Malpractice claims can identify trends in patient hazards and have been previously employed to better elucidate the opioid risks. This retrospective observational study examined all closed claims from a large malpractice carrier levied against pain medicine physicians. The resulting sample included 37 cases. Researchers found that improper medication management was the most common reason for a claim and only 27% resulted in payment. No claim filed when a provider terminated opioid therapy resulted in payment. Most of the patients who died in this study had cardiac, pulmonary, or psychiatric comorbidities. The authors recommend adhering to opioid prescribing guidelines, communicating opioid prescribing risks to patients, documenting those conversations, and monitoring for diversion as strategies to reduce malpractice claims. An Annual Perspective summarized opioid-related patient safety research.
Mohr H, Weiss M. Associated Press. November 27, 2018.