High Alert Medications & Concentrated
Electrolytes
Learning Objectives
Define and identify High Alert Medications
Share our experiences / reporting
Outline strategies to minimize risks
Identify strategies to improve
Reinforce policy & procedures
High Alert Medications
APP 1429-02 Look-Alike, Sound-Alike & High Alert Medication
ISMP Survey on High Alert Medications
2012
Drugs Considered High Alert Medications
% Site
Chemotherapy, oral & parenteral
93
Antithrombotic Agents
93
Insulin, IV
93
Potassium Chloride injection
89
Insulin, subcut (including pens & pumps)
84
Neuromuscular Blocking Agents
83
Epidural or Intrathecal Medications
82
Potassium Phosphate Injection
80
Medication Safety Alert Acute Care; 09 February 2012 vol 17, issue 3
Top 10 Medications Reported as Causing Harm
60
50
40
30
20
10
# of reports
Accounted for 199 / 465 (43%)
Harmful Incidents. (ISMP Canada;
2001-2005)
MedMarx 2008 High Alert Meds with Harm
Score E and Above
300
250
200
150
100
50
High Alert Medications: SRS Reports
Central Region: January - December 2014
160
140
120
135
117
100
80
60
40
20
0
61
42
31
31
20
17
30
15
Harm Category for High Alert Medication Reported Errors
January December 2014
180
160
140
120
100
80
60
40
20
0
N/S
A-Potential to B-Near Miss-Error C-Error reached
cause
did not reach the individual-No
Harm/Damage
individual
Harm/Damage
D-Required
monitoring to
confirm No
Harm/Damage
E-Temporary
Harm-Required
intervention
F-Temporary
Harm-Required
hospitalization
Not Applicable
Half of Preventable ADEs involve:
DRUG:
1. Opiates
2. Insulin
3. Anticoagulants
TOO MUCH LEADS TO:
U$3.5 billion is spent annually on extra medical costs of ADEs
Winterstein, A., Hatton, R., Gonzalez-Rothi, R., Johns, T., & Segal, R. (2002). Identifying clinically significant preventable adverse
drug events through a hospitals database of adverse drug reaction reports. Am. J. Health Syst. Pharm., 59(18), 17421749.
Retrieved from
Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington,
DC: The National Academies Press 2006.
Opiates
Common Risks: Opiates
Lack of leading zero
Ordered
, patient received 8 mg Morphine
Improper disposable of Transdermal Patches
Bolus dose, failing to re-program maintenance dose
Different rates and concentrations
Common Strategies: Opiates
Develop a quick reference sheet on PCA
Differentiate products
Use TALL man lettering
Employ Independent Double-Checks
Implement protocols for the use of PCA and other opioids
Proper patient education
Use conversion tables
Education for staff regarding PCA
Anticoagulants
Common Risks: Anticoagulants
Lack of standardization in names and packs
Complicated dosing regimens
Low Molecular Weight Heparin (LMWH) syringe designed for
adults only
Common Strategies: Anticoagulants
Standardize labels, packaging
Protected Standard Concentration
Anticoagulation Services
Counseling
Use protocols / smart pumps
Individualized monitoring and handoffs
Medication Reconciliation
Improved Information and Counselling
for Patients
At start of therapy (prescription)
On hospital discharge
At the first anticoagulant clinic
appointment
When necessary throughout
course of therapy
INSULIN
Common Risks: Insulin
Look-Alike Vials
Use of U or IU
Incorrect dose / rate
Lack of dose checking
Common Strategies: Insulin
Spell out Units and Numbers
Smart pump / double-check
Protected Standard Concentration
Independent double checks
Store separately / labels
Storage: Separate High Alert Medication (Look-Alike)
Chemotherapy Risks
Drug
Error and Outcome
Methotrexate
Administering daily instead of weekly (approximately 25
fatalities reported)
VinCRIStine
Accidental Intrathecal administration - Fatal
Lomustine
Oral agent administered daily instead of every 6 weeks,
hospitalization and death
CARBOplatin and
CISplatin
CISplatin administered at dose intensity appropriate for
CARBOplatin, fatal outcome
Common Risks: Chemotherapy
Miscommunication
Total course (or cycle) dose given every day
Substantial distance between Pharmacy and patient treatment
area (lack of communication)
Lack of health care information (labs, BSA)
Excessive interruptions
LASA / packaging
Lack of protocols and education
Common Strategies: Chemotherapy
Double check against actual order / protocol
Generic names / legible handwriting
No abbreviations / error-prone abbreviations
Avoid excessive precision (round off 919.57)
Date and time of prescriptions (for cycles)
Common Strategies: Chemotherapy
BSA dosing (mg / m2), when applicable mg / kg
Use updated lab information
Use Time Out for intrathecal administration
Patient / caregiver education
Communication,
communication,
communication
Contains High Alert Medication /
Concentrated Electrolytes
APP 1433-18: Concentrated Electrolytes
MUST be diluted, and admixed by Pharmacy
(if diluted, NOT a concentrated electrolyte)
INDEPENDENT double-check
MEDICATION segregation
APP 1433-18: Concentrated Electrolytes
Red Bins
o Patient care areas: Stored in locked cabinets
Crash Cart / Black Box (as applicable)
o Auxiliary label Contains High Alert Medication /
Concentrated Electrolytes
Storage - Red Bins with Lid
Storage of Concentrated Electrolytes Outside of
Pharmacy is Limited to (as applicable):
Concentrated
Electrolyte
Clinical Justification
Location by Clinical
for Concentrated
Care Area
Electrolyte
Quantity
Magnesium sulfate
50% or higher
concentration
Cardioplegia
Eclampsia
Torsades de pointes
Crash Carts
Cardiac / Liver OR
Emergency Medical
Services (EMS)
Main OR
Surgical Tower OR
Determined by
Region
Potassium chloride
2 mEq / mL or
higher
concentration
Cardioplegia
Cardiac / Liver OR
Main OR
Determined by
Region
Independent Double-Check
Procedure in which two healthcare professionals
check (alone and apart from each other, then compare results)
each component of prescribing, transcribing, dispensing and
verifying the medication before administering to the patient.
Dispensing
Verifying at time of
administration
One Stop Resource
HIS-CPR Enhancements
HIS-CPR Enhancements (cont)
Alerts Advisories
Max / Min Dosing
Interactions
Allergies
