Presentation on theme: "High-Alert Medications: Safeguarding Against Errors (Part 1)"— Presentation transcript:
1 High-Alert Medications: Safeguarding Against Errors (Part 1)
2 Learning Objectives Discuss the concept of high-alert medications Identify the many drug classes considered to be high-alert statusDescribe various strategies for safeguarding the use of high-alert medications
3 High-Alert Medications High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in errorErrors may not be more common with these than with other medications, but the consequences of errors may be devastatingI used the current ISMP definition
4 ISMP’s List of High-Alert Medications Adrenergic agentsAnestheticsAntiarrhythmicsAnticoagulantsCardioplegic solutionsChemotherapyDextrose ≥20%Dialysis solutionsElectrolytes (concentrated)Epidural/intrathecal agentsEpoprostenolInotropic agentsInsulin/hypoglycemicsLiposomal productsNarcoticsNeuromuscular blocking agentsNitroprussideOxytocinParenteral nutritionPromethazineRadiocontrast agentsSedativesSterile water for injectionThis is the most current ISMP list with web site location – suggest deleting the previous three slides and including only this one.
5 High-Alert Status of Drugs: Differences Between Nurses’and Pharmacists’ BeliefsMedication% Nurses% PharmDialysate solution6626IV adrenergic agonists9263IV adrenergic antagonists8143Liposomal forms of drugs6839Hypertonic sodium chloride7394Warfarin5975Subcutaneous insulin72Institute for Safe Medication Practices. ISMP Medication Safety Alert! October 16, 2003;8(21).
6 Drugs Most Frequently Considered High-Alert by Practitioners MedicationHigh-Alert?Parenteral chemotherapy98%IV potassium chloride96%Neuromuscular blockers94%Hypertonic sodium chloride91%IV insulin90%IV potassium phosphateIV heparin87%IV thrombolytics82%Institute for Safe Medication Practices. ISMP Medication Safety Alert! October 16, 2003;8(21).
7 Framework for Safeguarding High-Alert Medication Use
8 Primary Principles Reduce or eliminate the possibility of errors Make errors visibleMinimize the consequences of errors
9 Key Concepts in Safeguarding High-Alert Medications SimplifyReduce steps and number of optionsExternalize or centralize error-prone processesDifferentiate itemsAppearance, locationTouch, color, smell, etc.
10 Key Concepts in Safeguarding High-Alert Medications (continued) StandardizeCommunication and dosing methodsRedundancyCheck systems, back-ups
11 Key Concepts in Safeguarding High-Alert Medications (continued) RemindersImprove access to informationConstraints that limit access or useForcing functionsFail-safesUse of defaultsPatient monitoringFailure analysis for new products and procedures
12 Implement a Safety Checklist for High-Alert Drugs Develop policies regarding the use of high-alert drugsAssess and implement storage requirements of high-alert drugsDevelop and institute standardized order setsEnsure the process of evaluating potential formulary additions identifies high-alert medications
13 Number of Steps in the Process Error Probability Rate SimplifyProbability of no error when each step is 99% reliableNumber of Steps in the ProcessError Probability Rate11%2522%5039%10063%
14 Simplify Reduce the number of steps and options Computerized order entryUnit-dose dispensingDosing chartsLimited choice of concentrationPremixed solutionsDo not eliminate crucial redundancies
15 Key Concepts in Safeguarding High-Alert Medications (continued) Simplify and reduce number of options through standardizationUse a single heparin size/concentrationStandardize concentrations of critical care drug infusionsUse weight-based heparin protocol
16 Key Concepts in Safeguarding High-Alert Medications (continued) Externalize or centralize error-prone processes: IV drug preparationUse commercially prepared premixed productsPremixed magnesium sulfate, heparin, etc.Centralize preparation of IV solutionsPrepare pediatric IV medications in pharmacyOutsource of TPN and cardioplegic solutions
17 Key Concepts in Safeguarding High-Alert Medications (continued) Differentiate items that are similar but dangerous if confusedPurchase one of the products from another sourceIf hydroxyzine and hydralazine injections look alike, purchase one from another companyUse “TALL-man” letteringhydrOXYzine versus hydrALAZINEUse other means to “make things look different” or call attention to important informationUse stickers, labels, enhancement with pen or markerSee
18 Key Concepts in Safeguarding High-Alert Medications (continued) Differentiate items by touch, color, etc.Tactile cuesPlace tape on regular insulin vial for blind diabetic patientsOctagonal shape of neuromuscular blocker containerUse of colorUse red to “draw out” warningsColor coding also can be a source of errorSuggest eliminating “smell” - I like the idea but this is not mentioned in the chapter (at least not that I could find) and I am concerned that that someone might try to apply this to a hazardous drug.
19 Key Concepts in Safeguarding High-Alert Medications (continued) Bar code scan or separate problem products as effective deterrent for product selection errorsLook-alike packagingStore hydroxyzine and hydralazine tablets apartLook-alike drug namesDesign computer mnemonics so similar names do not appear on same screenAvoid placing similar names (carboplatin/cisplatin, vinblastine/vincristine) next to one another on a preprinted chemotherapy form or order entry computer screen
20 Key Concepts in Safeguarding High-Alert Medications (continued) Standardize order communicationCreate, disseminate, and enforce ordering guidelinesStandardize read-back procedure for verbal ordersStandardize dosage units in smart pumps and autocompoundersEliminate acronyms, coined names, apothecary system, use of nonstandard symbols, etc.TPN: IV nutrition or Taxol, Platinol, NavelbineIrrigate wound with TAB
21 Key Concepts in Safeguarding High-Alert Medications (continued) System of independent checks (redundancies)Probability that two individuals will make the same error is small; therefore, having one person check the work of another is essentialPCA pump rate and concentration set by one person with independent confirmation by anotherCalculations for pediatric patients, select high-alert medications, etc., performed independently by at least two individuals, with identical conclusions
22 Key Concepts in Safeguarding High-Alert Medications (continued) Use remindersPlace auxiliary labels on containers for clinical warnings and error prevention messagesDilute Before UseFor Oral Use OnlyIncorporate warnings into computer order processing and selection of medications from dispensing equipmentLabels on IV lines to prevent mix-ups between IV lines and enteral feeding linesProtocols, checklists, visual and audible alarmsSuggest not using the “check for pregnancy” example – Does this mean that you should only use it during pregnancy or does it mean not to use it in pregnancy?
23 Key Concepts in Safeguarding High-Alert Medications (continued) Improve access to informationComputerized drug information resources (handheld)Computer order entry systems that merge patient and drug information, provide warnings, screen orders for safety, etc.Readily available texts in current publicationPharmacists present in patient care areasInternet connectionI suggest removing the item about the medical librarian on clinical rounds to follow up on patients and staff information items – The librarian will not have the domain expertise to know what information should be provided to the patient. Also, the idea is not realistic.
24 Key Concepts in Safeguarding High-Alert Medications (continued) Use constraints that limit access in risky conditionsReduce access to dangerous items by careful selection of medications and quantities in storageLimit or prohibit access to pharmacy in nonaccredited facilitiesMove problem products out of reachRemove concentrated potassium chloride from clinical unitsSequester neuromuscular blockers from other medications
25 Key Concepts in Safeguarding High-Alert Medications (continued) Limit drug usePeer reviewed drug approval processStaff credentialing with restricted access or usage rightsAutomatic reassessment of ordersInstitute automatic stop ordersUse medications with reduced dosing frequencyEstablish parameters to change IV to PO as appropriate
26 Key Concepts in Safeguarding High-Alert Medications (continued) Forcing functions (“lock and key design”)Makes errors immediately visible; ensures that parts from different systems are not interchangeable; forces proper methods of useEnteral feeding tubes without Luer connection combined with systems that will not fit vascular access devicesOral syringe should not be able to fit onto an IV linePreprinted order forms or computer options that “force” selection from limited number of medications, available dosages, etc.
27 Key Concepts in Safeguarding High-Alert Medications (continued) Fail-safesUse products that design error out of the systemImplementation of automatic fail-safe clamping mechanism on IV infusion pumps has protected patients from free-flow and saved many livesDangerous order cannot be processed in computer system
28 Key Concepts in Safeguarding High-Alert Medications (continued) Use of defaultsPre-established parameters take effect unless action is taken to modifyClinical pathwaysDevice defaultsMorphine concentration default for PCA pumpPharmacy IV compounder defaults to drug concentrations available in pharmacy
29 Key Concepts in Safeguarding High-Alert Medications (continued) Patient monitoringMore frequent and closer attention to vital signs, including quality of respirationsMore frequent and closer attention to neurological signs and laboratory resultsInclude patient monitoring parameters in all protocols and order sets
30 Key Concepts in Safeguarding High-Alert Medications (continued) Failure analysis for new products prior to useFormal safety review (e.g., formulary committee, risk management committee) of new medications and drug delivery devicesExamine for ambiguous or difficult-to-read labeling, error-prone packaging, sound-alike product names, etc.Conduct a failure mode and effects analysis to proactively anticipate and prevent errors
31 ReferencesInstitute for Safe Medication Practices. ISMP’s list of high-alert medications. ISMP Medication Safety Alert! March 27, 2008;13(6).Institute for Safe Medication Practices. Survey on high-alert medications. Differences between nursing and pharmacy perspectives revealed. ISMP Medication Safety Alert! October 16, 2003;8(21).