18–1: Appendix 18–1 Policy Example: High-Alert Medications

I. PURPOSE:

This policy outlines the process for the safe use of high-alert medications.

II. DEFINITIONS:

When used in this policy these terms have the following meanings:

1. High-alert medications: Medications that have a higher risk of causing harm when an error occurs.

2. Independent double verification (IDV):

   1. Is performed by two staff members (as appropriate to the task, e.g., blood administration, breast milk retrieval) in the same proximity but separately, without prompting by another, as an independent cognitive task.

   2. Both professionals will dialog to confirm what was checked independently prior to administration.

   3. IDV of a medication also includes the following steps in addition to the two steps above:

      1. Performed by two professionals (e.g., nurse/pharmacist,/physician [within the approved LPN scope of practice]) in the same proximity but separately, without prompting by another, as an independent cognitive task.

      2. Each professional must check: the actual prescriber’s order, drug, calculation, concentration, and other information specific to the medication.

      3. Each professional performing the verification performs all calculations independently without knowledge of any prior calculations and documents the verification in the medical record.

III. POLICY:

It is the policy of the health system that:

1. All systems and data repositories relating to medication use (medication error reports, adverse drug event reports, etc.) shall be systematically evaluated on an ongoing basis to identify those medications in the hospital formulary determined to be high-alert medications.

2. Medications being added to the hospital formulary shall be evaluated for their high-alert potential.

3. Medications identified as high-alert shall be targeted for specific error reduction interventions.

4. The following three principles shall be followed to safeguard the use of high-alert medications:

   1. Reduce or eliminate the possibility of error (e.g., limit the number of high-alert medications on the hospital formulary; remove high-alert medications from the clinical areas).

   2. Make errors visible by detecting serious events before they reach the patient (e.g., follow the five rights and when appropriate utilize the independent double verification process).

   3. Minimize the consequences of errors (e.g., stock high-alert medications in smaller volume units of use minimizing the error effect if the medication was administered in error).

5. Engineering safety controls shall be used as appropriate.

IV. PROCEDURE:

1. The Pharmacy and Therapeutics Committee will approve all medications added to the formulary.

2. The following processes for safeguarding high-alert medication use have been implemented:

   1. Build in system redundancies (e.g., unit dose drug distribution).

   2. Use fail-safes (e.g., pumps with locking mechanisms).

   3. Reduce options (e.g., limit concentration available).

   4. Utilize engineering safety controls (e.g., oral syringes that will not fit IV tubing, computer systems that force the order of standardized products).

   5. Externalize or centralize error-prone processes (e.g., centralize IV solution preparations).

   6. Use differentiation (e.g., identify and isolate look-alike and sound-alike products, use generic names).

   7. Store medications appropriately (e.g., separate potentially dangerous drugs with similar names or similar packaging).

   8. Screen new products (e.g., inspect all new drugs and drug delivery devices for poor labeling and/or packaging).

   9. Standardize and simplify order communication (e.g., only approved abbreviations will be used, all verbal orders will be read back verbatim to the ordering physician).

   10. Limit access (e.g., high-alert medications will be securely stored).

   11. Use of constraints (e.g., pharmacy will screen all medication orders, automatic stop orders or duration limits).

   12. Standardize or automate dosing procedures (e.g., use of standard dosing charts rather than calculating doses based on weight or renal function when appropriate).

3. When initiating any high-alert medication by any route, and for those high-alert medications administered via pump, and with all subsequent bag/syringe changes and with dose changes requiring pump adjustment, the following must occur:

   1. Independent double verification, each professional will independently:

      1. Review/verify the physician order in the medical record (i.e., on the physician’s order sheet or in the clinical information system).

      2. Verify the correct medication, dose (all required dosage calculations must be done independently by each nurse), frequency/rate/titration, and route against the order.

         • 1) Note: After the initial IDV, ongoing titration in Level I areas is exempt from the IDV process for each continuing adjustment.

         • 2) Some medications require IDV of pump settings at change of shift (e.g., insulin).

         • 3) Additional information regarding medication-specific IDV requirements is available in the IDV Policy and Procedure.

   2. The nurse administering the medication will:

      1. Identify the patient using two acceptable identifiers.

      2. Verify the correct connection/patient access when administering the medication via an intravenous drip, trace the flow of the medication from the bag > to the pump > to the patient access, prior to hanging the medication.

      3. Document the verification.

4. When an infusion device with prebuilt infusion parameters is used and pre-set infusion parameters are not available for a high-alert medication (e.g., when the medication is new and not yet added to the library), independent double verification of the medication parameters programmed into the pump must occur prior to initiation of the infusion.

V. DOCUMENTATION:

As appropriate in the medical record or clinical information system.

VI. REFERENCES:

1. Institute for Safe Medication Practices (ISMP); ISMP’s list of high-alert medications. 2008.

2. Patient Care Policy and Procedure #0282, Independent Double Verification.

3. Patient Care Policy and Procedure #0500, Verbal Orders.

4. Patient Care Policy and Procedure #0700, Abbreviations.

5. Patient Care Policy and Procedure #0282, IDV.

6. Patient Care Policy and Procedure #5010, Anticoagulant Safety.

7. Patient Care Policy and Procedure #5020, Chemotherapy: Oncology/Hematology.

8. Patient Care Policy and Procedure #5070, Electrolyte Infusions.

9. Patient Care Policy and Procedure #5117, Insulin Intravenous Infusions.

10. Patient Care Policy and Procedure #5130, Medication Administration.

11. Patient Care Policy and Procedure #5131, Medfusion Syringe Infusion Pump.

12. Patient Care Policy and Procedure #5140, Medication Use Analysis/Error Prevention.

13. Patient Care Policy and Procedure #5150, Moderate/Deep Sedation/Analgesia.

VII. ATTACHMENTS:

High-Alert Medications/Classes, one page.

Source: Used by permission from Orlando Health, Orlando, FL. www.orlandohealth.com.