Complaints as Safety Surveillance
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. In the accompanying commentary, Jennifer Morris and Marie Bismark, MD, both of the University of Melbourne, discuss how patient complaints can provide insights about safety hazards and review remediation approaches for organizations to address high-risk physicians.