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Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

CMAJ Open

March 2017

Office of the Chief Coroner for Ontario (Lowe), Toronto, Ont.; Institute for Safe Medication Practices Canada (Hamilton, Greenall, Ma); St. Michael's Hospital, Health Quality Ontario and Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto (Dhalla); Department of Family and Community Medicine, St. Michael's Hospital, and Department of Family and Community Medicine, University of Toronto (Persaud), Toronto, Ont.

Background: Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies.

Methods: In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine.

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