Table 1: Summary of cases
CasePatient age, yrSexSettingOrdered or intendedAction precipitating deathIncident
181FemaleHospitalOrdered: hydromorphone 1 mg (0.5 mL from 2 mg/mL vial) subcutaneouslyAdministered: morphine 25 mg (0.5 mL from 50 mg/mL vial) subcutaneouslyAbout 5-fold excessive dose
222MaleHospitalInitial order:
morphine increased from 5 to 10 mg intravenously every 2 hours
Increased to:
hydromorphone 5 to 10 mg intravenously every 4 hours as needed		About 5-fold excessive dose
382MalePalliative careOrdered:
hydromorphone increased from 0.2 to 0.4 mg subcutaneously as necessary for pain management		Administered:
hydromorphone 4 mg (dose drawn from a 10 mg/mL concentration vial to give an actual dose of 4 mg)		About 10-fold excessive dose
486MaleNursing homeOrdered:
hydromorphone 0.2 mg/h intravenously.		Administered:
hydromorphone 2 mg/h intravenously		About 10-fold excessive dose
590FemaleHospitalInitial order:
long-acting morphine 15 mg twice daily
Second order: discontinuation of morphine; hydromorphone 2 mg orally every 4 h as needed		Administered:
both morphine and hydromorphone administered		About 2.5-fold excessive dose
642FemaleHospitalOrdered:
morphine 2 to 3 mg intravenously every 4 h as needed		Administered:
hydromorphone 3 mg intravenously		About 5-fold excessive dose
719FemaleHospitalOrdered:
hydromorphone 4 mg intravenously		Administered:
hydromorphone 4 mg intravenously		Administration despite sedation
891FemaleHospitalOrdered:
morphine 4 mg subcutaneously		Administered:
hydromorphone 4 mg subcutaneously		About 5-fold excessive dose