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