Table 1: Summary of cases.

Case	Patient age, yr	Sex	Setting	Ordered or intended	Action precipitating death	Incident
1	81	Female	Hospital	Ordered: hydromorphone 1 mg (0.5 mL from 2 mg/mL vial) subcutaneously	Administered: morphine 25 mg (0.5 mL from 50 mg/mL vial) subcutaneously	About 5-fold excessive dose
2	22	Male	Hospital	Initial 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
3	82	Male	Palliative care	Ordered: 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
4	86	Male	Nursing home	Ordered: hydromorphone 0.2 mg/h intravenously.	Administered: hydromorphone 2 mg/h intravenously	About 10-fold excessive dose
5	90	Female	Hospital	Initial 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
6	42	Female	Hospital	Ordered: morphine 2 to 3 mg intravenously every 4 h as needed	Administered: hydromorphone 3 mg intravenously	About 5-fold excessive dose
7	19	Female	Hospital	Ordered: hydromorphone 4 mg intravenously	Administered: hydromorphone 4 mg intravenously	Administration despite sedation
8	91	Female	Hospital	Ordered: morphine 4 mg subcutaneously	Administered: hydromorphone 4 mg subcutaneously	About 5-fold excessive dose