Managing Hospital Safety: Common Safety Concerns

(Hospital-focused presentation)Part 3 of 4

Managing Patient Safety: High-Risk Medications in the Hospital Setting

High-Alert Medications: A Cause for Concern

Why Are High-Alert Medicationsa Cause For Concern?

More likely to beassociated with

harm than other medications Harm leads to

poor outcomes for patients and

increased patientcare costs

Cause harm more commonly and the harm produced is

likely moreserious

Institute for Healthcare Improvement (IHI). Getting started kit: prevent harm from high-alert medications. http://www.ihi.org. Accessed January 29, 2009.

Medications Associated With the Highest Risk of Injury When Misused Are Known as High-Alert Medications1

1. The Institute for Safe Medication Practices. ISMP 2007 survey on high-alert medications: differences between nursing and pharmacy perspectives still prevalent. http://www.ismp.org/Newsletters/acutecare/articles/20070517.asp. Published May 17, 2007. Accessed January 29, 2009.

2. Institute for Healthcare Improvement. 5 million lives campaign. Getting started kit: Prevent harm from high-alert medications. Cambridge, MA: 2008.

3. The Joint Commission. High-alert medications and patient safety. Sentinel Event Alert. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_11.htm. Published November 19, 1999. Accessed January 29, 2009.

High-alert medications identified by key US safety organizations

ISMP1 IHI2 Joint Commission3

Parenteral chemotherapy Anticoagulants Insulin

IV insulin Narcotics and opiates Opiates and narcotics

Potassium chloride InsulinInjectable potassium chloride or phosphate

concentrate

IV unfractionated heparin Sedatives IV anticoagulants

Epidural/intrathecal drugsSodium chloride solutions

>0.9%

Categories of High-Alert Medications• Adrenergic agents• Anesthetic agents • Antiarrhythmics, IV • Antithrombotic agents • Cardioplegic solutions• Chemotherapeutic agents• Dextrose, hypertonic, ≥20%• Dialysis solutions,

peritoneal and hemodialysis• Epidural or intrathecal

medications

• Hypoglycemics, oral• Inotropic medications, IV • Liposomal forms of drugs• Moderate sedation agents, IV• Narcotics/opiates• Neuromuscular blocking

agents • Radiocontrast agents, IV• Total parenteral nutrition

solutions

Institute for Safe Medication Practices (ISMP). ISMP’s list of high-alert medications. http://www.ismp.org/Tools/highalertmedications.pdf. Accessed January 29, 2009.

Examples of ISMP Medication Safety Recommendations for Hospitals• Many recommendations address the common risk factors for

high-alert medications:– Process1

• Hospital formulary should contain minimal duplication of therapeutically equivalent products

• Make current protocols, dosing scales, and/or checklists for high-alert drugs easily accessible to prescribers, pharmacists, and nurses

• All inpatient drug orders should be entered into a computer and screened electronically against the patient’s current clinical profile for contraindications, interactions, and appropriateness of doses before drug administration

• Nurses and pharmacists should establish a clear, effective process for resolving conflicts about safety issues with prescribers and/or supervisors

Adapted from the Institute for Safe Medication Practices 2004.1

1. The Institute for Safe Medication Practices. 2004 ISMP Medication Safety Self Assessment® for Hospitals. http://www.ismp.org/selfassessments/Hospital/2004Hospsm.pdf. Accessed January 29, 2009.

Examples of ISMP Medication Safety Recommendations for Hospitals (cont’d)

• Many recommendations address the common risk factors for high-alert medications:– Medication administration1

• Labels for IV admixture containers should be visible, positioned correctly, and list the total volume of solution, the base solution, and the concentration or total amount of each drug additive contained

• Manufacturers’ prefilled syringes should be used for at least 90% of injectable products, rather than vials

• Readable labels that clearly identify drugs should be on all drug containers; drugs should remain labeled up to the point of administration

• All drug containers taken to the patient’s bedside should be labeled with drug name, strength, and dose

• All medications should be dispensed to patient-care units in labeled, ready-to-use UNIT-DOSES or in labeled UNIT-OF-USE containers

Adapted from the Institute for Safe Medication Practices 2004.1

1. The Institute for Safe Medication Practices. 2004 ISMP Medication Safety Self Assessment® for Hospitals. http://www.ismp.org/selfassessments/Hospital/2004Hospsm.pdf. Accessed January 29, 2009.

Please refer to the following Web link for ISMP Medication Safety Self Assessment® for Hospitals and for additional recommendations: www.ismp.org/selfassessments/default.asp.

Examples of ISMP Medication Safety Recommendations for Hospitals (cont’d)

• Medication administration1 (cont’d)

– Concentrations for infusions of high-alert drugs should be standardized to a single concentration that is used in at least 90% of cases

– With each new bag/bottle or change in the rate of infusion of selected high-alert drugs, one practitioner should prepare the solution for administration and a second practitioner should independently verify that the correct drug, drug concentration, rate of infusion, patient, channel selection, and line attachment have been selected prior to infusion

– Machine-readable coding (eg, bar coding) should be used to verify drug selection prior to dispensing and before administration

Adapted from the Institute for Safe Medication Practices 2004.1

1. The Institute for Safe Medication Practices. 2004 ISMP Medication Safety Self Assessment® for Hospitals. http://www.ismp.org/selfassessments/Hospital/2004Hospsm.pdf. Accessed January 29, 2009.

Please refer to the following Web link for ISMP Medication Safety Self Assessment® for Hospitals and for additional recommendations: www.ismp.org/selfassessments/default.asp.

Managing Hospital Safety: Focus on Insulin

Increased Hospital Safety Concerns1-3

High-Alert Medications (JCAHO)1

1. Insulin2. Opiates and narcotics3. Injectable potassium chloride or

phosphate concentration4. IV anticoagulants5. Sodium chloride solutions >0.9%

1. The Joint Commission. http://www.jointcommission.org. Accessed January 29, 2009. 2. The Institute for Safe Medication Practices (ISMP). http://www.ismp.org. Accessed January 29, 2009.3. New Tech Media. Senior Journal. http://seniorjournal.com/NEWS/Medicare/2008/20080804-CMSMoving.htm.

Accessed January 29, 2009.

Insulin Errors Directly Affect Inpatient Care• Insulin is a major contributor of injury-induced

medication errors within the hospital setting1

• Per Institute for Safe Medication Practices (ISMP), 11% of serious medication errors were associated with incorrect insulin administration2

• Insulin may be twice as likely to cause patient harm vs other reported medications based on MEDMARX data compiled by United States Pharmacopeia3

1. Hellman R. Endocr Pract. 2004;10(suppl 2):100-108. 2. Grissinger M. P&T. 2003;28(10):628.3. US Pharmacopeia Center for the Advancement of Patient Safety. USP patient safety CAPSLink. July 2003.

http://www.usp.org/pdf/EN/patientSafety/capsLink2003-07-01.pdf. Accessed January 29, 2009.