November 20, 2014: Decimal Point in New Strength of HYDROmorph Contin Leads to an Opioid Overdose
ISMP Canada received a report of a critical incident involving the high-alert medication HYDROmorph Contin (HYDROmorphone hydrochloride controlled-release capsules). In this incident, a patient newly admitted to a residential hospice was given an inadvertent opioid overdose, as a result of several contributing factors, including availability of a relatively new strength (4.5 mg) of the drug.
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