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High Alert Medication

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Eman Nasser

on 14 January 2015

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Transcript of High Alert Medication

Eman N. AlMutairi
High-Alert Status of Drugs:
Differences Between Nurses’
and Pharmacists’ Beliefs
Externalize or centralize error-prone processes: IV drug preparation
Use commercially prepared premixed products
Premixed magnesium sulfate, heparin, etc.
Centralize preparation of IV solutions
Prepare pediatric IV medications in pharmacy
Outsource of TPN and cardioplegic solutions

Our Goal is to Reduce HARM from HAMs
ISMP defined High Alert Medications as
Reduce harm
from high risk
level changes
Make clinical
area level
Make patient
level changes
Policies and Procedures

Procurment & monitoring usage
Labelling and storage
Monitor compliance

Education and training
Prescription and
Monitoring effects
Record keeping
According to one report
the most frequently associated with severe harm were:

• Anticoagulants
• Antibiotics (allergy related)
• Injectable sedatives
• Chemotherapy
• Opiates
• Antipsychotics
• Insulin
• Infusion fluid
National Patient Safety Agency. Patient Safety Observatory Report 4. Safety in Doses, July 2007, NPSA, London www.npsa.nhs.uk/patientsafety/medication-zone.
Goal 1: Identify Patients Correctly
Goal 2: Improve Effective Communication
International Patient Safety Goals
Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
Goal 5: Reduce the Risk of Health Care–Associated Infections
Goal 6: Reduce the Risk of Patient Harm Resulting from Falls
Goal 3: Improve the Safety of high-Alert Medications
What are High Alert Medications (HAMs)?

HAMs are medications that are most likely to cause SIGNIFICANT HARM to the patient, even when used as intended.

Many medications have large margin of safety
However, there is small number of medications have high risk to cause injuries
These medication are called
High Alert Medications
In 2000 the IOM published a book
Who make harmful mistakes?
Example of medication errors involving high alert medication
A patient receiving an infusion of fentanyl for pain control was ordered a 50 mcg bolus dose

but received 50 mLs.
Insulin was administered to the wrong patient based on blood sugar levels of another patient.
Two reports concerned patients receiving concentrated epinephrine 1:1,000 undiluted intravenously.
An intravenous heparin infusion was programmed to run at 150 mL/hr (the rate for the patient’s antibiotic) rather than the ordered rate of 10 mL/hr.

PREVENT: Reduce / eliminate the possibility of errors

IDENTIFY: Make errors visible

MITIGATE: Minimize the consequences of errors
Policies & Procedures
Standard list
LIMIT strengths and concentrations available in the formulary.

AVOID frequent changes in brands.

Stock only small vials of high-alert medications.

Procurment and monitoring usage
NOT be stored as floor stock of the patient care units.
Locked cabinet accessible only to authorized nursing staff
Narcotic and controlled locked in special cabinet

Pharmacy will provide red labels to all containers used for storing HAMs in clinical areas


Accurate prescription:
Generic drug name
Dosage form
Strength or concentration
Route of administration

Parameters (weight, age, labs) to finalize dose.
NOT use abbreviations except the approved ones
NOT use trailing zero
(Ex: 5.0mg can be mistaken as 50mg)

The Prescription MUST
Infusions / concentrated electrolytes MUST specify:
Strength of dilution.
Rate of infusion.
(Ex: Norepnephrine 4 mg in 50 ml NS, run at 5 ml/hr)
Incomplete physician orders will NOT be processed to prevent any error that may cause significant harm to the patient.
Pharmacist MUST clarify from physician.
Physician MUST enter new order on HIS
Pharmacist MUST document by completing the clarification form.

RPh 1:

Review order for completeness & clarity
Check dose
Adjust if needed
Make required calculations.
Call another pharmacist
Preparing and Dispensing
RPh 2:

Independently make the required calculation
RP Tech:
Prepare medication
RP- Final checker:

Right patient
Right medication, right dose, right frequency, right route and the quantity.
Stick the HAMs / auxiliary labels

RN 1:
Check HAM according physician order
Check the dose calculation
Question medication order unusual.
Prepare all IV equipment at bedside.
Before administration, Call another RN

RN 2:
Read the order and verify the 7 rights.
Independently check the calculation
Check that the infusion pump settings are programmed at the proper rate against the order
A Patient's Story...
Benzodiazepines- primarily midazolam (Sedatives, often used for ‘conscious’ sedation during a procedure)
Chemotherapeutic agents (for cancer treatment)
Intravenous digoxin (used in the treatment of specific heart rhythm and rate abnormalities)
Dopamine and dobutamine (used to treat low blood pressure and depressed heart function)

- Heparin, intravenous and warfarin (blood thinners - prevent blood clot formation)
- Insulin (regulates blood sugar levels in diabetics)
- Lidocaine (local anaesthetic used intravenously for specific cardiac rhythm
- Intravenous magnesium sulfate (an electrolyte found in the blood: therapeutic
levels are required for normal body cellular function, particularly in the heart)

- Opiate narcotics (used in the treatment of acute and chronic pain conditions)
- Neuromuscular blocking agents (paralyze muscles - including the muscles for
- Potassium phosphate and potassium chloride (electrolytes found in the blood -
required for normal cell function especially the respiratory muscles and the heart)
- Intravenous sodium chloride, high concentrations (an electrolyte found in the
blood - required for normal cellular function, including in the brain)
Some LASA are Considered HAMs
Storage and Labeling
Simplify and reduce number of options through standardization
Use a single heparin size/concentration
Standardize concentrations of critical care drug infusions
Use weight-based heparin protocol

Differentiate items that are similar but dangerous if confused
Purchase one of the products from another source
If hydroxyzine and hydralazine injections look alike, purchase one from another company
Use “TALL-man” lettering
hydrOXYzine versus hydrALAZINE
Use other means to “make things look different” or call attention to important information
Use stickers, labels, enhancement with pen or marker

Cont. Safeguards
Institute for Safe Medication Practices. ISMP Medication Safety Alert! Feb 9, 2012.
More frequent and closer attention to vital signs, including quality of respirations
More frequent and closer attention to neurological signs and laboratory results
Include patient monitoring parameters in all protocols and order sets

Patient monitoring
Our goal is to reduce HARM from HAMs
Thank You!
IPSG.1: Identify Patients Correctly
Reliably identify the individual as the person for whom the service or treatment is intended;
Match the service or treatment to that individual.
Goal 2: Improve Effective Communication
The hospital develops and implements a process for reporting critical results of diagnostic tests.
The hospital develops and implements a process for handover communication.
Goal 3: Improve the Safety of High-Alert Medications
Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
Goal 5: Reduce the Risk of Health Care–Associated Infections
Goal 6: Reduce the Risk of Patient Harm Resulting from Falls
Thehospitalimplementsaprocessforassessingallinpatientsandthoseoutpatientswhosecondition, diagnosis, situation, or location identifies them as at high risk for falls.
Thehospitalimplementsaprocessfortheinitialandongoingassessment,reassessment,and intervention of inpatients and outpatients identified as at risk for falls based on documented criteria.
Measuresareimplementedtoreducefallriskforthoseidentifiedpatients,situations,andlocations assessed to be at risk.
The hospital has adopted currently published, evidence-based hand-hygiene guidelines. Thehospitalimplementsaneffectivehand-hygieneprogramthroughoutthehospital.
Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the hospital.
Thehospitalusesaninstantlyrecognizablemarkforsurgical-andinvasiveprocedure–siteidentification that is consistent throughout the hospital.
Surgical-andinvasiveprocedure–sitemarkingisdonebythepersonperformingtheprocedureand involves the patient in the marking process.
The hospital uses a checklist or other process to document, before the procedure, that the informed consent is appropriate to the procedure; that the correct site, correct procedure, and correct patient are identified; and that all documents and medical technology needed are on hand, correct, and functional.
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