A fatal 10-fold hydromorphone overdose prompts ISMP Canada warning on home palliative care

A patient receiving palliative care at home was prescribed 1 mg of hydromorphone to help manage their pain. Instead, they received four separate 10 mg injections over approximately 10 hours. By the time the mistake was caught and the patient was rushed to hospital, where naloxone was administered, it was too late. They died several days later from overdose- and disease-related complications. The incident is the focus of a new two-part safety bulletin from the Institute for Safe Medication Practices Canada, examining medication safety in home-based palliative care. As more Canadians choose to end their lives at home, community pharmacies and family caregivers are increasingly managing complex medications outside of hospitals, said the organization. In this case, investigators identified a series of system failures that together allowed the error.Chief among them was the concentration of the medication itself. Because hydromorphone 1 mg/mL was unavailable, the prescribed dose had to be prepared from a higher dose product, increasing the risk of a calculation error. The prepared syringe was also left unlabelled, meaning no independent double check could be performed. Investigators further found that caregivers had difficulty distinguishing signs of opioid toxicity from the natural decline commonly seen in patients nearing the end of life. The medication came from a palliative symptom management kit, a package of medications commonly dispensed by community pharmacies to help patients manage pain, nausea, agitation and shortness of breath at home. The kits have become increasingly common in end-of-life care, allowing symptoms to be treated quickly without repeated trips to hospital. However, they also mean powerful medications are being prepared and administered more often outside traditional clinical settings. The report follows a companion bulletin published last month that reviewed 79 medication incidents reported in community-based palliative care between 2020 and 2025. Incorrect dosing was the most common error, accounting for 41% of cases. Communication failures—including misunderstood verbal orders, confusing order sets and delays in relaying medication changes—were also recurring contributors. Three of the five medications most frequently involved were opioids. To reduce the risk of similar incidents, ISMP Canada called for lower-concentration injectable opioids to be included in symptom management kits, reducing the need for bedside dose calculations. The organization is also recommending standardized syringe labels, mandatory independent double checks for high-alert medications and wider availability of naloxone kits paired with caregiver education. For community pharmacies, ISMP Canada recommends listing both the prescribed dose in milligrams and the corresponding volume in millilitres on prescription labels. It’s further encouraging pharmacies to supply syringes appropriate for the prescribed dose. Caregivers should also receive direct counselling on how medications should be prepared and administered safely.

A fatal 10-fold hydromorphone overdose prompts ISMP Canada warning on home palliative care

Register for free access or login.

Related Topics