Teaching From Catastrophe: Using Therapeutic Misadventures From Hydromorphone to Teach Key Principles in Clinical Pharmacology

C principles of clinical pharmacokinetics and pharmacodynamics that form the basis for safe drug practices are important to convey to medical learners. However, the discipline of clinical pharmacology as applied at the clinic and bedside in academic health centers has been in decline for the past 25 years. Although all medical students are provided with information on pharmacokinetics and pharmacodynamics of drugs in general and opioids in particular, this exposure occurs during their preclinical years. However, formal training of medical students in the core principles of clinical pharmacology should take place during their senior year to properly link the information conveyed directly to patient care to foster rational drug prescribing habits. This is recognized as a deficiency in medical education across the United States by the Association of American Medical Colleges (AAMC). A path forward in the medical school curriculum has been outlined by the AAMC. This has coincided with statements contained in the leading journals and organizations representing clinical pharmacology across the globe that underscore the importance for practicing academic clinical pharmacologists to be the leaders in this process of reform. Unfortunately, during this same period, the number of medical schools in the United States that offer fourth-year coursework in clinical pharmacology has declined from 20% in 1974 to 9% in 2007. This milieu provides the backdrop for the current situation whereby information in therapeutics is conveyed to medical students through an apprenticeship model by some combination of anecdotal experience of postgraduate physicians-in-training and/or faculty mentors. The series of patient cases in this report represents clear deviations in good clinical practice, resulting in medical catastrophe from the improper use of hydromorphone. As such, the most direct causes of these unnecessary deaths are mistakes on the part of the health care providers involved, leading to insufficient patient monitoring and incorrect hydromorphone administration. However, fundamental knowledge deficits typically underlie these more immediate causes of human error in thirdorder “why” internal quality investigations in hospitals to improve future patient safety. Indeed, had the fundamental principles of clinical pharmacology been properly understood, it is likely that these therapeutic misadventures would have been averted. Deaths from opioids, including hydromorphone, usually occur from parenteral administration and derive from root causes of errors in drug dosing and frequency, combined use with other sedatives, and inattention to underlying patient conditions that predispose to drug toxicity. This report adds