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


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.


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.


  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 ...

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