HYDROmorphone Safety Self-Assessment Introduction

The HYDROmorphone Safety Self-Assessment is designed to:

  • Heighten awareness of the distinguishing characteristics for safe use of HYDROmorphone; and
  • Create a baseline for hospital efforts to enhance the safety of HYDROmorphone use and evaluate these efforts over time.

The self-assessment is divided into 6 sections covering the prescribing, dispensing, administration and monitoring of HYDROmorphone, as well as management of overdose and patient and family education. Self-assessment items are provided to help you evaluate your practice in each area.

Why a self-assessment specific to HYDROmorphone?

HYDROmorphone, a known high-alert medication, is one of the top 3 medications involved in harmful incidents reported to ISMP Canada and has also been implicated in fatal medication incidents worldwide. Despite the continued efforts of regulatory bodies, safety organizations, and clinicians in improving patient safety, HYDROmorphone incidents continue to occur. These continued incidents support the need for high leverage interventions to prevent further harmful incidents. While many of the self-assessment items will be applicable to use of other opioids, this assessment highlights safeguards specific to HYDROmorphone.

About Medication Safety Self Assessment Programs (MSSA)

ISMP Canada is not a standard-setting organization. As such, the self-assessment items in this document are not intended to represent a minimum standard of practice and should not be considered as such. In fact, some of the self-assessment items represent innovative practices and system enhancements that are not widely implemented in most hospitals today. However, their value in reducing errors is grounded in scientific research and expert analysis of medication errors and their causes. Assessment findings are intended for internal use and become more useful as repeat assessments are performed to see where improvements have been achieved over time.


The HYDROmorphone Safety Self-Assessment and its components are copyrighted by ISMP Canada and may not be used in whole or in part for any other purpose or by any other entity except for self-assessment of medication systems by hospitals and other healthcare facilities as part of their ongoing quality improvement activities.