Definition:

medication that have a higher likelihood of causing injury if they are misused. Errors with these medications are not necessarily more frequent- just their consequences may be more devastating. Some high alert medications also have high volume use.

TOP FIVE HIGH ALERT MEDICATIONS

Insulin Opiates and narcotics Injectable potassium chloride or

phosphate concentrate Intravenous anticoagulants (heparin) Sodium chloride solutions above 0.9

percent. Ref. ISMP 2007 Survey on High-Alert Medications

INSULIN

Common risk factor:

Lack of dose check systems Insulin & heparin vials kept in close

proximity to each other on a nursing units, leading to mix-ups

Use of “U” or “IU” Incorrect rates being programmed

into an infusion pump

Suggested Strategies:

Establish a check system whereby one nurse prepares the dose and another nurse reviews it.

Do not store insulin and heparin near each other.

Spell out the word “units” instead of “U”

Build in an independent check system for infusion pump rates and concentration settings.

OPIATES AND NARCOTICS

Common risk factors: Narcotics kept as floor stock Confusion between morphine

and hydropmorphone PCA ( patient controlled

analgesia) errors regarding rate and concentrations.

Suggested Strategies:

Limit opiates and narcotics in Floor stock

Education (sound-alike, hydromorph.)

Implement PCA protocols Double-check drug and pump

settings Prepare infusion in Pharmacy

INJECTABLE POTASSIUM CHLORIDE OR PHOSPHATE CONCENTRATE

Common risk factor:

Mixing pot. chloride/ phosphate Request for unusual concentrations Unclear labels Storing concentrated potassium

chloride/phosphate outside the pharmacy

Suggested strategies

Remove Pot. Chloride/ phosphate from wards

Use commercially available premixes Standardize and limit concentrations Prepare, double-check in pharmacy

INTRAVENOUS ANTICOAGULANTS (HEPARIN)

Common risk factor: Unclear labelling regarding

concentration and total volume Multidose-containers Confusion between heparin and

insulin due to similar measurement units and proximity.

Suggested strategies:

Standardized concentrations and use premixed solutions.

Use only single-dose containers. Separate heparin and insulin.

SODIUM CHLORIDE SOLUTIONS ABOVE 0.9 PERCENT

Common risk factor: Storing sodium chloride solutions above 0.9 percent on nursing units.

Large number of concentrations/formulations available.

No double check system in place.

Suggested strategies:

Limit access of sodium chloride solutions above 0.9 percent and remove from nursing units.

Standardize and limit drug concentrations.

Double check pump rate, drug, concentration and line attachments.

ACTIONS THAT CAN BE TAKEN IN CLINICAL AREAS

Risk awareness- be aware of high alert products in your area.

Review floor stock to reduce availability of items, as well as, quantities.

Use of shelf labelling which incorporates TALLman lettering.

Separate storage for easily mistaken medicines.

Additional product labels. Read the labels three times (RL3). Insure proper and correct programming of

infusion pumps.

Independent double checking system ( example: IV medication and infusion pumps).

Standardize the prescribing / order entry/IV infusion labelling/pump settings.

Know the medications that you administer example dose, route, frequency, effect, common adverse effects, and monitoring ( laboratory

PRINCIPLES FOR IMPROVED SAFETY OF

HIGH ALERT MEDICATIONS

1. ELIMINATE THE POSSIBILITY OF ERROR

Reducing the number of medications in the formulary.

Reducing the number of concentrations and volumes to those clinically appropriate for most.

Remove / minimize high alert medications from clinical areas, where possible.

2. MAKE ERRORS VISIBLE

Have two individuals independently check the product or setting.

Examples: IV pumps and epidural medications, insulin doses drawn up in syringe, and chemotherapy and TPN production.

3. MINIMIZE THE CONSEQUENCES OF ERROR.

Minimize the size of vials or ampules in the patient care area to the dose comonly needed ( example: heparin in single dose vial versus 10 ml vials

Reduce the total dose of High Alert Medications in continous IV drip bags(example: 12,500 units of heparin in 250 ml vs 25,000 units in 500 ml) to reduce risk when it runs away, because it will.

Thank You