lecture 8 high alert drugs 1

8/9/2019 Lecture 8 High Alert Drugs 1

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High-Alert

Medications: Safeguarding

Against Errors

(Part 1)



Learning Objecties

• Discuss the concept of high-alert

medications

• Identify the many drug classes considered tobe high-alert status

• Describe various strategies for safeguarding

the use of high-alert medications



High-Alert Medications

• High-alert medications are drugs that bear

a heightened risk of causing significant

patient harm when used in error

• Errors may not be more common with

these than with other medications, but the

consequences of errors may be

devastating



!SMP"s List of

High-Alert Medications• drenergic agents• nesthetics• ntiarrhythmics• nticoagulants

• !ardioplegic solutions• !hemotherapy• De"trose #$%&• Dialysis solutions

• Electrolytes 'concentrated(• Epidural)intrathecal agents• Epoprostenol• Inotropic agents

• Insulin)hypoglycemics• *iposomal products• +arcotics• +euromuscular blocking

agents• +itroprusside• "ytocin• arenteral nutrition• rometha.ine• /adiocontrast agents• 0edatives• 0terile water for in1ection

www2ismp2org)3ools)highalertmedications2pdf



High-Alert Status of #rugs:#ifferences $et%een &urses"

and Phar'acists" $eliefsMedication &urses Phar'

Dialysate solution 44 $4

I5 adrenergic agonists 6$ 47

I5 adrenergic antagonists 89 :7

*iposomal forms of drugs 48 76

Hypertonic sodium chloride ;7 6:

<arfarin =6 ;=

0ubcutaneous insulin 47 ;$

Institute for 0afe >edication ractices2 ISMP Medication Safety Alert! ctober 94, $%%7?8'$9(2



Medication High-Alert

arenteral chemotherapy 68&

I5 potassium chloride 64&

+euromuscular blockers 6:&

Hypertonic sodium chloride 69&

I5 insulin 6%&

I5 potassium phosphate 6%&

I5 heparin 8;&

I5 thrombolytics 8$&

#rugs Most *re+uentl, onsidered

High-Alert b, Practitioners

Institute for 0afe >edication ractices2 ISMP Medication Safety Alert! ctober 94, $%%7?8'$9(2



*ra'e%or. for Safeguarding

High-Alert Medication /se



Pri'ar, Princi0les

• /educe or eliminate the possibility of

errors

• >ake errors visible• >inimi.e the consequences of errors



e, once0ts in Safeguarding

High-Alert Medications

• 0implify

@ /educe steps and number of options

• E"ternali.e or centrali.e error-proneprocesses

• Differentiate items

@ ppearance, location @ 3ouch, color, smell, etc2




High-Alert Medications (continued)

• 0tandardi.e

@ !ommunication and dosing methods

• /edundancy @ !heck systems, back-ups





• /eminders

• Improve access to information

• !onstraints that limit access or use• Aorcing functions

• Aail-safes

• Bse of defaults

• atient monitoring

• Aailure analysis for new products andprocedures



!'0le'ent a Safet, hec.list

for High-Alert #rugs

• Develop policies regarding the use of high-

alert drugs

• ssess and implement storage requirementsof high-alert drugs

• Develop and institute standardi.ed order sets

• Ensure the process of evaluating potentialformulary additions identifies high-alert

medications



&u'ber of Ste0sin the Process

Error Probabilit,2ate

9 9&

$= $$&

=% 76&

9%% 47&

Si'0lif,

robability of no error when each step is 66& reliable



Si'0lif,

• /educe the number of steps and options @ !omputeri.ed order entry

@ Bnit-dose dispensing @ Dosing charts

@ *imited choice of concentration

@ remi"ed solutions

• Do not eliminate crucial redundancies





Simplify and reduce number of options through

standardization

• Bse a single heparin si.e)concentration

• 0tandardi.e concentrations of critical care drug infusions

• Bse weight-based heparin protocol





Externalize or centralize error-prone processes:

I drug preparation

• Bse commercially prepared premi"ed products

@ remi"ed magnesium sulfate, heparin, etc2

• !entrali.e preparation of I5 solutions

@ repare pediatric I5 medications in pharmacy

@ utsource of 3+ and cardioplegic solutions





ifferentiate items that are similar but dangerousif confused • urchase one of the products from another source

@ If hydro"y.ine and hydrala.ine in1ections look alike,purchase one from another company

@ Bse C3**-man lettering

• hydrF.ine versus hydr*GI+E

• Bse other means to Cmake things look different orcall attention to important information

@ Bse stickers, labels, enhancement with pen or marker





ifferentiate items by touch" color" etc#

• 3actile cues

@ lace tape on regular insulin vial for blinddiabetic patients

@ ctagonal shape of neuromuscular blocker

container

• Bse of color @ Bse red to Cdraw out warnings

@ !olor coding also can be a source of error





$ar code scan or separate problem products aseffecti%e deterrent for product selection errors

• *ook-alike packaging

@ 0tore hydro"y.ine and hydrala.ine tablets apart

• *ook-alike drug names

@ Design computer mnemonics so similar names donot appear on same screen

@ void placing similar names 'carboplatin)cisplatin,vinblastine)vincristine( ne"t to one another on apreprinted chemotherapy form or order entrycomputer screen





Standardize order communication

• !reate, disseminate, and enforce ordering guidelines

@ 0tandardi.e read-back procedure for verbal orders

@ 0tandardi.e dosage units in smart pumps andautocompounders

• Eliminate acronyms, coined names, apothecarysystem, use of nonstandard symbols, etc2

@ 3+ I5 nutrition or 3a"ol, latinol, +avelbine @ Irrigate wound with 3





System of independent chec&s 'redundancies(

• robability that two individuals will make the same

error is small? therefore, having one person check the

work of another is essential

@ ! pump rate and concentration set by one person with

independent confirmation by another

@ !alculations for pediatric patients, select high-alert

medications, etc2, performed independently by at leasttwo individuals, with identical conclusions





)se reminders • lace au"iliary labels on containers for clinicalwarnings and error prevention messages

@ Dilute efore Bse @ Aor ral Bse nly

• Incorporate warnings into computer order processingand selection of medications from dispensing equipment

• *abels on I5 lines to prevent mi"-ups between I5 linesand enteral feeding lines

• rotocols, checklists, visual and audible alarms





Impro%e access to information

• !omputeri.ed drug information resources 'handheld(

• !omputer order entry systems that merge patient and

drug information, provide warnings, screen orders for

safety, etc2

• /eadily available te"ts in current publication

• harmacists present in patient care areas

• Internet connection





)se constraints that limit access in ris&y

conditions

• /educe access to dangerous items by careful selection

of medications and quantities in storage

• *imit or prohibit access to pharmacy in nonaccredited

facilities

•>ove problem products out of reach @ /emove concentrated potassium chloride from clinical

units

@ 0equester neuromuscular blockers from other

medications





*imit drug use

• eer reviewed drug approval process

•0taff credentialing with restricted access or usagerights

• utomatic reassessment of orders

• Institute automatic stop orders

• Bse medications with reduced dosing frequency• Establish parameters to change I5 to as

appropriate





+orcing functions ',loc& and &ey design(• >akes errors immediately visible? ensures that parts

from different systems are not interchangeable?

forces proper methods of use @ Enteral feeding tubes without *uer connection

combined with systems that will not fit vascular accessdevices

@ ral syringe should not be able to fit onto an I5 line

@ reprinted order forms or computer options that Cforceselection from limited number of medications, availabledosages, etc2





+ail-safes

• Bse products that design error out of the system

@ Implementation of automatic fail-safe clamping

mechanism on I5 infusion pumps has protected

patients from free-flow and saved many lives

@ Dangerous order cannot be processed in computer

system





)se of defaults • re-established parameters take effect unless action

is taken to modify

@ !linical pathways

@ Device defaults

• >orphine concentration default for ! pump

• harmacy I5 compounder defaults to drug

concentrations available in pharmacy





Patient monitoring

• >ore frequent and closer attention to vital signs,

including quality of respirations

• >ore frequent and closer attention to neurological

signs and laboratory results

• Include patient monitoring parameters in all protocols

and order sets





+ailure analysis for ne. products prior to use

• Aormal safety review 'e2g2, formulary committee, risk

management committee( of new medications and

drug delivery devices

@ E"amine for ambiguous or difficult-to-read labeling,

error-prone packaging, sound-alike product names,

etc2

@ !onduct a failure mode and effects analysis toproactively anticipate and prevent errors



2eferences

Institute for 0afe >edication ractices2 I0>Js list of

high-alert medications2 ISMP Medication Safety Alert!

>arch $;, $%%8?97'4(2

Institute for 0afe >edication ractices2 0urvey on

high-alert medications2 Differences between nursing

and pharmacy perspectives revealed2 ISMP

Medication Safety Alert! ctober 94, $%%7?8'$9(2

lecture 8 high alert drugs 1

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