HIGH-ALERT MEDICATION SAFETY BEST PRACTICE: /Filter/DCTDecode Learn more information here. Addressing drugs given by a certain route of administration (e.g., intrathecal, epidural) or in special populations (e.g. Explicit and Standardized Prescription Medicine Instructions. Plymouth Meeting, PA 19462. Accessed November . This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. Further, to assure relevance and completeness, the clinical staff at ISMP and members of the ISMP advisory board were asked to review the potential list. Note that even if you have an account, you can still choose to submit a case as a guest. The hospitals high-alert medication list should be updated as needed and reviewed at least every 2 years. Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the humancomputer interaction. A failure mode and effects analysis or self-assessment tool also might help identify underlying risks associated with each high-alert medication/class of medications. Low-leverage risk-reduction strategies such as staff education, passive information, and the use of reminders should be bundled together with high-leverage risk-reduction strategies such as forcing functions and fail safes, maximizing access to information, limiting access or use, constraints and barriers, standardization, and simplification. Please select your preferred way to submit a case. Horsham, PA; Institute for Safe Medication Practices: 2018. Learn more information here. Safe Practice Recommendations: We encourage hospitals to take the time to reassess their current list of high-alert medications and any plans that have been enacted to reduce the risk of errors and harm with these drugs. ISMP Publishes 2020-2021 Consensus-Based Medication Safety Best Practices for Hospitals ISMP issued its 2020-2021 Targeted Medication Safety Best Practices for Hospitals to help identify, inspire, and mobilize widespread national action to address recurring problems that continue to cause fatal and harmful errors Additional medications to consider for the list may include new drugs added to the formulary, potentially harmful drugs used temporarily during a shortage (which can be removed once the shortage is over), and medications involved in potentially harmful errors based on the hospitals internal reporting process, even if the drug is not on the ISMP list. She is actively practicing in a community hospital and has had over 20 years of experience in community and acute care settings. anticoagulants. However, this is just the first step in safeguarding the use of high-alert medications. You must have JavaScript enabled to use this form. /Height 237 Developing a principle-based approach to safe medication practices. study, administration of the high-alert medications described by ISMP has been shown to be a risk factor for harm in neonatal patients (Stavroudis et al., 2010). The hospital may also send memos to staff to increase their awareness of the risks or establish strategies that impact only one aspect of the medication use processusually drug storage. NEW! magnesium sulfate injection. Advanced practice nursing students' identification of patient safety issues in ambulatory care. Horsham, PA: Institute for Safe Medication Practices; 2021. moderate sedation agents, IV (e.g., dexmedetomidine, midazolam, moderate and minimal sedation agents, oral, for children (e.g., chloral hydrate, midazolam, ketamine [using the parenteral form]), neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium), sodium chloride for injection, hypertonic, greater than 0.9% concentration, sterile water for injection, inhalation and irrigation (excluding pour bottles) in containers of 100 mL or more, sulfonylurea hypoglycemics, oral (e.g., chlorpro, potassium chloride for injection concentrate, Standardizing the ordering, storage, preparation, and administration of these medications, Improving access to information about these drugs, Limiting access to high-alert medications, Using auxiliary labels and automated alerts. Please select your preferred way to submit a case. /Length 64894 and high alert medications as such Separate the storage of such items in the carts Verify, re-verify and triple check before giving medications, especially high alert medications - the six rights can help, but may not prevent errorsmore than this is required. Long-Term Trends of Psychotropic Drug Use in Nursing Homes. All Rights Reserved. hXio8O!_fpA>;>3Ln,JrWnh{~ V&Yu*R2BSw('. https://www.ismp.org/recommendations/high-alert-medications-long-term-care-list. Strategy, Plain Strategies may include: How to cite:Institute for Safe Medication Practices (ISMP). Ambulatory care sites such as long-term care facilities, long-term acute care facilities, dialysis facilities, ambulatory surgery centers, and the pharmacies that provide services to them should also reference the ISMP List of High-Alert Medications in Long-Term Care (LTC) Settingsand/or the ISMP List of High-Alert Medications in Acute Care Settings. ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications. Work-arounds observed by fourth-year nursing students. << Specifically target clinical areas with an increased likelihood of a short or limited patient stay (e.g., emergency department, perioperative areas, infusion clinics, dialysis centers, radiology, labor and delivery areas, catheterization laboratory, outpatient areas). Copyright 2023 Haymarket Media, Inc. All Rights Reserved Economic analysis of the prevalence and clinical and economic burden of medication error in England. Among medication error reports submitted to PA-PSRS, approximately one out of four reports involve high-alert medications. Learn more information here. Avoid bringing oxytocin infusion bags to the patients bedside until it is prescribed and needed. The high-alert medications were: amiodarone, digoxin, dopamine, epinephrine, fentanyl, gentamycin, heparine, insulin, morphine, norepinephrine, phenytoin, potassium, propofol and tacrolimus. opium tincture. (Note: manual independent double-checks are not always the optimal Strategies must be sustainable over time. The ISMP is relying on ambulatory-care and community settings to use this updated list as a resource to identify the high-alert medications prescribed, stored, dispensed, and/or administered in their organizations or the facilities they serve. https://ismpcanada.ca/resource/definitions-of-terms/. Telephone: (301) 427-1364. * All forms of insulin, SC and IV, are considered high-alert medications. High-Alert Medication Learning Guides for Consumers. The following table, adapted from the ISMP US High-Alert List3, is provided as a guide. JFIF Adobe e C Definition of ISMP high-alert medications: High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Additional Resources ASHP Center on Medication Safety and Quality Institute for Safe Medication Practices (ISMP) Manual: Behavioral Health These specific medications have been singled out for special emphasis to bring attention to the need for distinct strategies to prevent the types of errors that occur with these medications. During June and July 2018, practitioners responded to an ISMP survey designed to identify which drugs were most frequently considered high-alert medications by . Published 2019. The list will be informed by an environmental scan, consultation with Canadian health care practitioners, consumers, and their caregivers, and medication incidents reported to the Canadian Medication Incident Reporting and Prevention System (CMIRPS). October 1, 2021 Horsham, PA: Institute for Safe Medication Practices; 2021. High-alert medications are drugs that bear a heightened Sites, Contact Diamond icons indicate key drugs in the Dosage tables. The effects of electronic prescribing by community-based providers on ambulatory medication safety. 128 0 obj <>stream . Another patient with diabetes receives a 5-fold overdose of U-500 insulin after a nurse draws the dose into a U-100 syringe, and a double-check by another nurse fails to detect the error. endstream endobj 10 0 obj <> endobj 11 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC]/Properties<>/Shading<>/XObject<>>>/Rotate 0/TrimBox[0 0 612 792]/Type/Page/u2pMat[1 0 0 -1 0 792]/xb1 0/xb2 612/xt1 0/xt2 612/yb1 0/yb2 792/yt1 0/yt2 792>> endobj 12 0 obj <>stream Another woman receives a rapid infusion of magnesium sulfate postpartum instead of oxytocin, despite staff awareness of prior mix-ups. 1 0 obj Plymouth Meeting, PA 19462. Sites, Contact This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors. High-alert medications in long-term care include the following.*. opioids. Should I report? Developing separate lists for medications identified as high-alert and/or hazardous Organizations determine how staff and practitioners will be educated regarding processes for managing these medications. Institute for Safe MedicationPractices Us. endstream endobj startxref https://www.ismp.org/resources/three-new-best-practices-2022-2023-targeted-medication-safety-best-practices-hospitals, ISMP Adds Seven Name Pairs to List of Drug Names with Tall Man (Mixed Case) Letters, Gaps in Recalls of Home-Use Medical Devices Top ECRIs Hazards List for 2023, Take a Leap in Your Professional Development, Medication Safety Officers Society (MSOS). In. Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. Medication adverse events in the ambulatory setting: a mixed-methods analysis. For neonatal and pediatric patients, contrast agent IVP orders shall be given by either the physician or the . ISMP; 2021. annual review). Sources to identify high -risk medications for the purposes of responding to this item can include the ISMP High Alert Medication List, Beer's Cr iteria, Joint Commission's High Alert Medication lists, or other authoritative resources. /Type/XObject To assure relevance and completeness, the clinical staff at ISMP, members of ISMPs community/ambulatory care advisory board, and other safety and clinical experts in the US were asked to review the list and potential changes. Search All AHRQ Monroe PS, Heck WD, Lavsa SM. /BitsPerComponent 8 5200 Butler Pike stream Worklife balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis. The keys to success are as follows: Both outcome and process measures should be established and data should be collected routinely to determine the effectiveness of risk-reduction strategies for high-alert medications. Rockville, MD 20857 It is not on the costs. This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. Regularly assess for risk in the systems and practices used to support the safe use of medications by using information from internal and external sources (e.g., Food and Drug Administration (FDA), The Joint Commission, ISMP). High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. A clinical reminder about the safe use of insulin vials. 17 In this case, in a prescription calling for L-tryptophan for the 18-month-old patient, the pharmacy compounded and dispensed baclofen, which was inadvertently administered, leading to a dose that was 20 times higher than the . ISMP; 2021. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. Reporting medication errors: residents with diabetes. Barcode Medication Administration that we will unquestionably offer. Plymouth Meeting, PA 19462. improving access to information about these drugs; July 29, 2020 View More See More About Hospitals Health Care Providers Medicine Specific to High-Risk Drugs Incorporating quality and safety values into a CLABSI simulation experience. Standardizing the ordering, storage, preparation, and administration of these . Information distortion in physicians' diagnostic judgments. Lists of High-Alert Medications ISMP creates and periodically updates a list of high-alert medications. such as standardizing the ordering, storage, The organization identifies, in writing, its high -alert and hazardous medications . And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. aFMEA: failure mode and effects analysis bADC: automated dispensing cabinet cPN: parenteral nutrition dMARs: medication administration records, Institute for Safe MedicationPractices The Institute for Safe Medication Practices (ISMP) provides resources addressing high-alert medications, including its Medication Safety Self Assessment for High-Alert Medications and the ISMP List of High-Alert Medications in Acute Care Settings. A list of high-alert medications is relatively useless unless it is up-to-date, known by clinical staff, and accompanied by robust risk-reduction strategies more effective than awareness, manual double-checks, staff education, and appeals to be careful. Many of these strategies should be translated for use with other medications. Rockville, MD 20857 Institute for Safe Medication Practices Institute for Healthcare Improvement. Potential for wrong route errors with Exparel. ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. This list may be used to determine ^N5#?frqtR ]tE}eb8kbd_>VI. Policies, HHS Digital The original list was developed in 2008, which included input from community pharmacy practitioners who participated in focus groups or responded to an ISMP survey on the topic. The following list of specific high-alert medications come form the ISMP. Submitted to PA-PSRS, approximately one out of four reports involve high-alert medications in long-term (. 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