High Alert Medications
Basic Medication Safety (BMS) Certification Course
King Saud bin Abdulaziz University for Health Sciences, Ministry
of National Guard – Health Affairs
Learning Objectives
Define and identify High Alert Medications
Share our experiences / reporting
Identify common risks
Outline strategies to improve and minimize risks
Reinforce policy & procedures
High Alert Medications
Medications that pose an
risk of causing significant
to patients if used in
APP 1429-02 Look-Alike, Sound-Alike & High Alert Medication
Top 10 Medications Reported as MedMarx 2008 High Alert Meds with
Causing Harm Harm Score E and Above
Accounted for 199 / 465
# of reports 300
60 (43%) Harmful Incidents.
(ISMP Canada; 2001-2005) 250
50
40 200
30 150
20 100
10
50
0
0
Reported Medication Errors / Near Misses for
Top Four High Alert Medications
2015, 2016 and 2017 - Central Region (KAMC) Total HAM:
2015 = 527
2016 = 814
250 2017 = 814
200
150
2015
100 2016
2017
50
0
Antithrombotic Opiates/Narcotic Chemotherapeutic Insulin
Agents Agents Agents
NCCMERP Categorizing Medication Errors for All
High Alert Medication Events
2015, 2016 and 2017 - Central Region (KAMC)
300
274
247 248
250
209
200 187
174
142
2015
150 133 135
2016
2017
100
46
50 40 38
29 37 35
17 11
9 3 4
0 1 2 0 0 1 0 0 1 0 1 0 0
0
A B C D E F G H I NA <N/S>
Half of Preventable ADEs involve:
DRUG TOO MUCH LEADS TO:
Opiates Respiratory depression
Insulin Hypoglycemia
Anticoagulants Bleeding
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 hospital’s database of adverse drug reaction reports. Am. J. Health Syst. Pharm., 59(18), 1742–1749. Retrieved from
Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National
Academies Press 2006.
Case:
44 year old male
History of PE on Warfarin
Admitted for bilateral hydronephrosis, with acute renal failure for bilateral
nephrostomy tube placement
Post-nephrostomy tube the anticoagulation was resumed with
Enoxaparin 120 mg q 12 hr in the setting of severely compromised renal
function
Patient was transferred to ICU with clinical picture of shock, which turned
to be hemorrhagic, complicated by multi-organ failure and death
Ultrasound of abdomen showed evidence of intra-abdominal collection
Anticoagulants
Percentage of Reported High Alert Medication Events
22% during 2017 at KAMC-Riyadh
24% during 2016 at KAMC-Riyadh
Common Risks
Lack of standardization in names and packs
Complicated dosing regimens
Low Molecular Weight Heparin (LMWH) syringe designed
for adults only
Anticoagulants
Common Strategies
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
Opiates
Percentage of Reported High Alert Medication Events
24% during 2017 at KAMC – Riyadh
23% during 2016 at KAMC – Riyadh
Common Risks
LASA (Morphine and HYDROmorphone)
Lack of leading zero
Ordered .8 mg, patient received 8 mg Morphine
Bolus dose, failing to re-program maintenance dose
Different rates and concentrations
Improper disposable of Transdermal Patches
Opiates
Common Strategies
Differentiate products
Use TALL man lettering
Use conversion tables
Time Out prior to intrathecal injection and ONLY intrathecal
meds will be in the procedure area
Education for staff regarding PCA
Develop a quick reference sheet on PCA
Implement protocols for the use of PCA and other opioids
Proper patient education
Chemotherapy
Percentage of Reported High Alert Medication Events
18 % during 2017 at KAMC-Riyadh
15 % during 2016 at KAMC-Riyadh
Cases
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 CISplatin administered at dose intensity
and CISplatin appropriate for CARBOplatin, fatal outcome
Chemotherapy
Common Risks
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
Route of administration: Intravenous vs. Intrathecal
Chemotherapy
Common Strategies
Drugs are ONLY stored in Pharmacy
Standard chemotherapy order sets
Orders must be signed by an authorized Consultant
Double check against actual order / protocol
No abbreviations / error-prone abbreviations
Avoid excessive precision (round off 919.57)
Non-Oncology indications: Order sets have dosing, route
safeguards programmed in them
Chemotherapy
Common Strategies: Cont.
Use of personal protective equipment to reduce employee
exposure to hazards
Dispense VinCRIStine (and other vinca alkaloids) in a minibag of
a compatible solution and not in a syringe
Weekly dosage regimen default for oral Methotrexate in
electronic systems when medication orders are entered.
Body Surface Area dosing (mg / m2), when applicable mg / kg
Use updated lab information
Patient / caregiver education
Communication
Insulin
Percentage of Reported High Alert Medication Events
8% during 2017 at KAMC Riyadh
13% during 2016 at KAMC Riyadh
Common Risks
Look-Alike Vials
Use of “U” or “IU”
Incorrect dose / rate
Lack of dose checking
Insulin
Common Strategies
Spell out “Units” and “Numbers”
Smart pump / double-check
Protected standard concentration of Adults
Order sets for
Perioperative Management of a Diabetic Patient’
Regular
Insulin IV Infusion Scale in Intensive Care Department
Insulin Infusion Protocol in Cardiac Sciences
Basal-Bolus-Corrective Subcutaneous Insulin Protocol in Internal
Medicine
Store separately / labels
Concentrated Electrolytes
Common Risks
Concentrated Electrolytes
Common Strategies
Stored in Red Bins with Lids
Patient care areas: Stored in ADC
locked Lidded
Crash Cart / Black Box (as
applicable)
Auxiliary label “High Alert / Conc.
Electrolyte: Must Be Diluted”
Standardized medication labels
APP 1433-18: Concentrated Electrolytes
Concentrated Electrolytes
Common Strategies: Cont.
Storage of Concentrated Electrolytes Outside of Pharmacy is Limited to
(as applicable)
Concentrated Clinical Justification for Location by Clinical Care
Quantity
Electrolyte Concentrated Electrolyte Area
Magnesium sulfate • Cardioplegia • Crash Carts Determined
4 mEq/mL or higher • Eclampsia • Cardiac / Liver OR by Region
concentration • Torsades de pointes • Emergency Medical
Services (EMS)
• Main OR
• Surgical Tower OR
Potassium chloride • Cardioplegia • Cardiac / Liver OR Determined
2 mEq / mL or higher • Main OR by Region
concentration
General Strategies For High Alert
Medications
General Strategies for High Alert Medications
TALLman lettering
‘LASA’ on label, when applicable
“High Alert” on storage label
High Alert Medications must be stored in Red Bins using
Standardized Medication Labels
Medication which must be stored in Red Bins with Lids
Concentrated Electrolytes
Parenteral Skeletal Muscle Relaxants (Paralyzing agents)
Patient care areas: Stored in ADC locked Lidded
CPOE with clinical decision support, providing immediate warnings
if unsafe orders are entered
General Strategies for High Alert Medications
Use of smart infusion pumps with dose
checking software enabled
Order sets
Independent Double-Check (IDC)
Procedure in which two healthcare
professionals separately check (alone and
apart from each other, then compare
results) each component of prescribing, Done without
distractions
transcribing, dispensing and verifying the
medication before administering to the
patient
Dispensing
Verifying at time of administration
General Strategies for High Alert Medications
APP 1429-02: Look-Alike/Sound-Alike And High Alert Medications, January- Appendix D
General Strategies for High Alert Medications
APP 1429-02: Look-Alike/Sound-Alike And High Alert Medications, April 2017 - Appendix C
Information available at One Stop Resource
Alerts Advisories at HIS-CPR
Alerts Advisories
Max
Interactions
Allergies
