1. Standardized Medication Concentrations for Parenteral Infusion
Medication Management:
Standardized Medication Concentrations for Parenteral Infusion
Revised: February 19, 2014

2. Agenda Medication Management Provincial Parenteral Manual
Background
Provincial Parenteral Manual
Roll-out & Transition
Access & Support
Standardized Medication Concentrations (SMCs)
SMC Lists & Policy
What you need to do
Next Steps
Medication Management
Background – an overview of what is medication management/safety and how standardized medication concentrations tie into med management
Provincial Parenteral Manual (PPM)
Roll-out & Transition
Access & Support
Standardized Medication Concentrations (SMCs)
SMC Lists & Policy
What you need to do – action items
Next Steps

3. Medication Management
Mission
Vision
Values
Collaborative approach to prevent and minimize medication errors and near misses to increase patient safety
Addresses all medication aspects from prescription, selection, preparation, and dispensing to the administering of medication and ongoing monitoring of patients
Structures
Medication Management
Medication Concentration
Narcotics Safety
Heparin Safety
Antimicrobial Stewardship
Others?
Concentrated Electrolytes
High Alert Medication
Medication Reconciliation
Processes
Principles
It is important to understand that the Standardized Medication Concentration project is only one component of the broader Medication Management Program.
Within the Medication Management Program, there are various initiatives such as:
Medication reconciliation
medication concentration
narcotics safety
heparin safety
antimicrobial stewardship
concentrated electrolytes
high alert medications and
others
The Standard Mediation Concentration (SMC) is one of the projects that falls under the High Alert Medication initiative within Medication Management.
The main focus of Medication Management is to increase and improve patient safety:
with a Collaborative approach to prevent and minimize medication errors and near misses and
Address all medication aspects from prescription, selection, preparation, and dispensing to the administering of medication and ongoing monitoring of patients
Medication management provides the overarching strategies, structure, processes, policies, principles as well as the necessary education and training to meet Covenant Health’s organizational mission, vision and values to work towards increased patient safety.
Policies
Strategies
Education and Training

4. Provincial Parenteral Monographs (PPM)
The new Provincial Parenteral Monographs provides:
Single common parenteral monograph throughout the province
Ensures patient safety and consistent medication administration and management
Electronic reference for drug therapy guidelines and parenteral drug information
Provincial Parenteral Manual - Link
Although PPM can be access electronically, a hard copy must be maintained for downtime instances
A Provincial Parenteral Monograph is a reference manual consisting of the approved administration information for individual parenteral medication, as well as a userguide.
Having a Provincial Parenteral Monograph will enhance patient safety and care by providing:
Single common parenteral monograph throughout the province
Ensures patient safety and consistent medication administration and management (i.e. this will minimize confusion and potential for error when patients are transferred from zone to zone, site to site, across the province)
Electronic reference for drug therapy guidelines and parenteral drug information
No need to maintain multiple parenteral monographs for the same medication – this will lead to reduction in duplication efforts and risk of inconsistencies with maintaining multiple references
*** Although PPM can be access electronically, a hard copy must be maintained for downtime instances
NOTE: The new Provincial Parenteral Monographs are NOT a comprehensive drug reference – if further information required, please consult other sources (i.e. Drug Information Services)
NOTE: The new Provincial Parenteral Monographs are NOT
a comprehensive drug reference – if further information required, please consult other sources (i.e. Drug Information Services)

5. Provincial Parenteral Monographs (PPM)
Ongoing roll-out of the new PPM will take place as therapeutic drug classes are completed
Use existing site specific monographs until new provincial monograph is available
CompassionNet (homepage)
Diagram shows how to locate the New Provincial Parenteral Monograph:
access the CompassionNet homepage
across the top blue bar, you will see the “Parenteral Manual” (click on that)
this will direct you to the AHS Pronvicial Parenteral Manual on the InSite page
click on the “Provincial Parenteral Manual” icon in the middle of the page
that should direct you to the provincial monographs
** note that all the old legacy sties will link directly to the new AHS monographs. If there is no new drug monograph updated, the site will directly like you back to the old legacy parenteral monograph
Parenteral Manual (top blue bar)
AHS Provincial Parenteral Manual (InSite page)
New Provincial Parenteral Monographs
Old legacy sites will link to new AHS monographs
No new monograph updated
Use existing old legacy parenteral monographs

6. Click Here

7.
Click Here

8.
** note that all the old legacy sties will link directly to the new AHS monographs. If there is no new drug monograph updated, the site will directly like you back to the old legacy parenteral monograph

9. Standardized Medication Concentrations (SMCs)
What are SMCs:
Medication infusions which are mixed according to a limited number of pre-determined drug concentrations
Focused on high alert medications
Established based on stakeholder input, focusing on the Institute for Safe Medication Practices’ (ISMP) list of high- alert medications
Took into account: legacy lists, parenteral drug monographs, stakeholder feedback, leading practices, availability from manufacturer, and concentrations implemented at other sites within Canada & USA
Familiarize yourself with these SMC Facts:
What is the purpose of the new AHS Standardized Medication Concentrations for Parenteral Administration policy and procedures?
The purpose of the new policy and procedures is to increase patient safety by decreasing the number of concentrations and volume options available for the same medication. This will reduce the risk that health care providers will select, dispense, or administer the wrong concentration/dose.
What are standardized medication concentrations?
Standardized medication concentrations (SMC) are medication concentrations that have been established based on stakeholder input for specific formulary parenteral medications, focusing on the Institute for Safe Medication Practices (ISMP) List of High-Alert Medications. The medications for which standardized concentrations have been established will differ for adult, pediatric and neonatal patients. There will be a set of standardized concentrations appropriate for each patient grouping – adults, pediatrics, and neonates. For some medications there will be more than one standardized concentration.
Will the same standardized medication concentrations be used across the province or will they be standardized by zone?
The same standardized concentrations will be used in all AHS facilities and these concentrations can be found in the Alberta Health Services Provincial Parenteral Drug Manual monographs. Until all facilities in the province can convert to the provincial standardized concentrations legacy or zone standardized concentrations can be used.
Why are we standardizing across the province?
AHS is one organization and therefore Accreditation Canada applies all the standards and ROPs to the organization as a whole. Also, as patients are transferred between zones, it is safer for the same concentrations to be employed in each zone to prevent medication errors that are occurring due to dissimilar concentrations utilized in each zone.
Is there a standard concentration for all injectable medications?
No. The focus for standardizing medication concentrations is the medications on ISMP’s List of High-Alert Medications.
What are High Alert Medications?
High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.
Are these the standard concentrations to be used on all patients?
Provincial Standardized concentrations have been developed for adult patients. Different, but appropriate standardized concentrations have been developed for neonatal patients. Provincial standardized concentrations for pediatric patients will be developed in the near future.
Are these the standard concentrations to be used for all parenteral routes?
No. The SMC list and each drug monograph will indicate whether the concentration is for a continuous infusion or an intermittent infusion.
Where do I find information on how to mix these concentrations?
See the parenteral drug monographs in the Alberta Health Services Provincial Parenteral Manual.
Will I find all of these concentrations in my infusion pump drug library?
Zones/sites will load any of the concentrations that they will use into the pump drug library. Depending on the size of the site and the services offered, not all of the concentrations or even medications may be used so the decision may be not to add them all to the pump drug library. However, if a need for another of the SMC is identified in the future, it should then be added to the pump drug library.
How come some of these medications are provided in a ready-to-administer format from the manufacturer, some are mixed in Pharmacy, and some must be mixed on the nursing unit?
Providing medications to the patient care area in a ready-to-administer format is the safest method. Unfortunately, very few drugs are available in Canada for purchase from the manufacturer in a ready-to-administer format. If they are available, Pharmacy services will try to purchase them. If they cannot be purchased then pharmacy will mix those that they can. This will be limited by the availability of sterile manufacturing services within the facility/zone, hours of service, staff resources, stability of the product, and frequency of use. Other Health Care Professionals will be responsible for mixing those medications that are not available premixed and should follow the mixing instructions in the drug monographs.
If my pump does not have a drug library do I still have to use the standardized concentrations?
Yes. Refer to the parenteral drug monographs in the Alberta Health Services Provincial Parenteral Manual for the concentration and mixing instructions.
Do I always have to use the standardized concentration?
Yes. By consistently using the SMC the risk of administering the wrong dose is decreased. That being said, there may be rare situations where the patient’s clinical condition precludes the use of a standardized concentration and a different concentration would be safer to use. In those cases, the prescriber must indicate the reason for a non-standardized concentration on the order and specify the preferred concentration.
Can I use a different volume?
Not for adult patients. Standardized volumes are included for each adult standardized concentration. For some drugs more than one volume size is available to meet the differing clinical needs of our patients.
Can you give me more details about the Independent double checks mentioned in the policy?
A draft AHS Independent Double Check Policy is currently in development. It will be vetted to stakeholders for input.
Does the prescriber’s order need to include a concentration?
A legal medication order must include the drug name, dose, route, and schedule for administration. The concentration does not need to be identified in the order. That being said, some sites/zones may have a practice in place that requires the concentration to be specified in the order for certain medications or in certain patient care environments. If so, this policy does not negate that practice. Where there is more than one standardized concentration there must be a site/zone procedure for clarifying the concentration and documenting that concentration on the patient’s chart.
Who is responsible for implementing the provincial standardized medication concentrations and the related policy and procedures?
The Zone Accreditation Implementation Teams and the Zone Medication Management Committees will be leading the implementation process.   
Who will be updating the pre-printed care orders?
The Zone Accreditation Implementation Teams and the Zone Medication Management Committees will be leading the implementation process and will be making this determination depending on the current zone practice.
Why doesn’t one department do all of the auditing?
Since all AHS environments and pumps are not consistent auditing the use of standardized concentrations is considered a shared responsibility. Each zone/site shall determine how they will proceed with auditing. Pharmacy can audit concentrations if prescriber orders received in Pharmacy include concentrations, or where medications are mixed in Pharmacy. Other Health Care Professionals, such as Nurses or Emergency Medical Services can audit concentrations they mix in the patient care environments. At site where smart pumps are used, data can be downloaded monthly or quarterly or annually. Where no smart pumps exist a one day or one week manual audit of medication administration records or infusion sheets or an observational audit, conducted quarterly or annually may be an option.

10. Standardized Medication Concentrations (SMCs)
Two (2) NEW Standardized Medication Concentration Lists:
Adult Standardized Medication Concentration List:
Currently, a total of 50 drugs with 104 concentrations
Neonatal Standardized Medication Concentration List:
*** April 1st: begin smart pump software upgrade & drug libraries updates
*** Revise pre-printed patient care orders and mixing sheets based on new Standardized Medication Concentrations List
The complete adult and neonatal drug lists can be seen by clicking on the above icons
NOTE: Roll-out for Insulin and Vasopressin will need to be deferred

11. Standardized Medication Concentrations (SMCs)
Why SMC Lists?
Safety
Minimizing medication errors to ensure patient safety
Decreasing number of concentration and volume options available for the same medication reduces the risk that a healthcare provider will select, dispense, or administer the wrong concentration
Standardization and Consistency
Reduce the number of steps and processes and the reliance on human memory and vigilance
Compliance
Accreditation Canada’s Medication Management ROP 2.5 – Major Test for Compliance:
“The orgnizational limits and standardizes concentrations and volume options available for high-alert medications”
standardization and consistency:
reduces nurse mixing times
when medication infusions are mixed according to limited number of pre-determined drug concentrations, this can reduce:
product selection errors
calculation errors
accidental mismatch between infusion concentrations, the medication order and the slection choice on the smart pump and/or automated dispensing maching
dosing errors during patient transfers
medication infusions

12. Standardized Medication Concentrations (SMCs)
Facts:
Medication errors are the LARGEST identified source of preventable hospital medical errors
Parenteral Administration errors are three (3) times as likely to cause harm or death compared with other errors
79% of reported harmful or fatal medication errors involve the IV route
58% of these errors occurred during administration of the medication
Healthcare expenses due to preventable errors cost Canadians $750 million/year
A hospital patient can expect to be subjected to more than one (1) medication error a day (Institute of Medicine 2006)
1/3 of nurses time on medication administration
majority “hunting & gathering”
IV medications mixed on care units with different concentrations for each clinical program area
errors on patient transfer or shift change or staff reassignment
product selection errors
preparation on units time consuming
High-risk therapies
(e.g.) Chemotherapy, HAM, PCA, Epidurals, TPN
complicated, stressful, multiple steps
Complexity of IV medications
dose, volume, calculations, compatibilities, labeling, expiry dating, pumps, tubing, catheters, rates of infusion
Pharmaceutical Calculations
More than 1 in 6 medication errors involves a calculation error
81% of nurses unable to correctly calculate medications 90% of the time - Shane.R. Am J Health-System Pharm. 2009, 66(Supp) 542-8
1 in 10 IV infusions in an ICU are prepared or administered in error (2/3 of ICU meds are give IV)
Statistic are from:
The Canadian Adverse Events study (May 2004)
The Canadian Institute for Health Information
The Institute of Medicine
The Canadian Association of Pediatric Health Centers – Canadian Pediatric High Alert Medication Delivery; Opioid Safety Toward a Change in Practice. ISPM Canada January 28, 2010

13. Standardized Medication Concentrations (SMCs)
Errors in the Medication Use Process:
So we know that a large number of Preventable medication errors are occurring in our hospitals , but for us to act on these, we need to know where the errors are occurring.
Studies indicate that Medication errors can be made at various stages throughout the medication process.
39% of them occur at the prescribing stage,
12% occur at the transcribing stage,
11% occur at the dispensing stage,
and 38% occur at the administration stage of the medication process.
So it appears that the areas we should address first to decrease medication errors would be Prescribing and Administering.
But we need to look further.
_______________
We need to look at where in the medication process do the most harmful errors occur.
28% of the errors that occur during prescribing cause harm, only 11% during transcribing & 28% of the errors that occur during dispensing cause harm.
However, 51% of the errors that occur during the Administration stage cause Harm.
So it now appears that the Administration stage is the area we should focus on to decrease medication errors.

14. Standardized Medication Concentrations (SMCs)
Facts:
We are Human – Humans are Fallible!
Sometimes, we make mistakes, no matter how familiar we are
We must design our work processes to help us reduce the possibility of mistakes/errors and ensure that mistakes/errors are detected and corrected.
Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoent tihng is that the frist and lsat ltteer be at the rghit pclae. The rset can be a tatol mses and you can sitll raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh
- We are all human and have the gift of

15. Standardized Medication Concentrations (SMCs)
Policy & Procedure:
Ordering Medications
Concentrations may or may not be part of the order
If ordering a non-SMC, must document clinical reason why and indicate clearly the preferred medication concentration
Processing Medication Orders
Concentrations to be clarified by a Health Care Professional and documented as per site processes on chart
The Policy and Procedure provides the overarching processes for SMC and have been broken down into : a) ordering medications; b) processing medication orders; c) preparing medications; d) administering medications; and e) auditing – compliance for audits
We will go through some key points in each of the mentioned processes
Important notes:
Our policy is still in development and will be coming out for further feedback. The list is not subject to change and will be the going live April 1st.
Whenever possible, pharmacy will endeavor to provide medication in a ready to administer format either by preparing it or by purchasing premade from the manufacturer. When the product is not available pre-mixed from pharmacy, HCPs shall be responsible for mixing meds following the mixing instructions found in the provincial parenteral manual. When more than one standardized medication is provided as ward stock, Pharmacy is responsible for labeling the higher concentration with this auxiliary label.
If a non-standardized concentration is prepared, a different label is required to be placed on the product.

16. Standardized Medication Concentrations (SMCs)
Policy & Procedure:
Preparing Medications
Use ready-to –administer format whenever/wherever possible
Use parenteral monographs for mixing instructions
The Policy and Procedure provides the overarching processes for SMC and have been broken down into : a) ordering medications; b) processing medication orders; c) preparing medications; d) administering medications; and e) auditing – compliance for audits
We will go through some key points in each of the mentioned processes
Important notes:
Our policy is still in development and will be coming out for further feedback. The list is not subject to change and will be the going live April 1st.
Whenever possible, pharmacy will endeavor to provide medication in a ready to administer format either by preparing it or by purchasing premade from the manufacturer. When the product is not available pre-mixed from pharmacy, HCPs shall be responsible for mixing meds following the mixing instructions found in the provincial parenteral manual. When more than one standardized medication is provided as ward stock, Pharmacy is responsible for labeling the higher concentration with this auxiliary label.
If a non-standardized concentration is prepared, a different label is required to be placed on the product.
Labels & Instructions
Standard Concentrations
No label required
High Concentrations
Non-Standardized Concentrations
IDC on calculations & preparation +

17. Standardized Medication Concentrations (SMCs)
Policy & Procedure:
Administering Medications
Utilize smart pump drug libraries
If non-SMC are used, manual programming of the pump is required with verification via an IDC
Auditing
Pharmacy to audit compliance by reviewing: infusions dispensed, medication orders, MARs, and/or patient charts
Nursing to audit compliance using data from: smart pumps, MARs, and/or patient charts
The Policy and Procedure provides the overarching processes for SMC and have been broken down into : a) ordering medications; b) processing medication orders; c) preparing medications; d) administering medications; and e) auditing – compliance for audits
We will go through some key points in each of the mentioned processes
Important notes:
Our policy is still in development and will be coming out for further feedback. The list is not subject to change and will be the going live April 1st.
Whenever possible, pharmacy will endeavor to provide medication in a ready to administer format either by preparing it or by purchasing premade from the manufacturer. When the product is not available pre-mixed from pharmacy, HCPs shall be responsible for mixing meds following the mixing instructions found in the provincial parenteral manual. When more than one standardized medication is provided as ward stock, Pharmacy is responsible for labeling the higher concentration with this auxiliary label.
If a non-standardized concentration is prepared, a different label is required to be placed on the product.

18. Standardized Medication Concentrations (SMCs)
What do you need to do?
Nursing
CNEs to notify staff on new SMCs and how to how to mix and handle orders (either with no specified SMCs, or with non-SMC specified)
Identify sources required: mixing sheets, pocket cards, posters, etc.
Units to ensure appropriate drug supply in areas of med storage not supplied by Pharmacy (i.e. crash carts)
Ensure smart pumps have version 12 drug library after April 1st
Audit compliance with SMCs (i.e. data from smart pumps, using MARs and/or patient profiles/charts)
Let’s talk about what needs to be done in the various units to prepare for the April 1st implementation.

19. Standardized Medication Concentrations (SMCs)
What do you need to do?
Pharmacy
Amend pharmacy computer system to reflect new SMCs
Update stock in pharmacy and on nursing units if needed
Update wardstock lists
Purchase or make products whenever possible
Update sterile manufacturing worksheets for IV room if needed
Train staff on how to handle orders (either with no SMC specified, or with the wrong SMC specified)
Audit compliance with SMCs (i.e. review of orders, infusions dispensed, review of MARs/patient profiles/charts)
Let’s talk about what needs to be done in the various units to prepare for the April 1st implementation.

20. Standardized Medication Concentrations (SMCs)
What do you need to do?
Prescribers
Ensure medication order comply with SMCs when ordering standardized concentrations (i.e. magnesium sulfate)
Ensure using SMCs when mixing on own (i.e. anesthetists)
Specify preferred concentration and clinical reason why SMC will not meet the patient’s needs of want to use and non-SMC
All users of PPCOs
Ensure PPCOs comply with SMCs and revise as needed
Let’s talk about what needs to be done in the various units to prepare for the April 1st implementation.

21. What Now? Communicate Educate Familiarize & Learn Lead
Now that we know what needs to be done on the various units for the SMC implementation, let’s talk about what you, as an individual can do to help with the SMC implementation on April 1st.
Learn and Familiarize yourself with:
what is SMC and the reason and need for the SMC – we talked a lot about this and it’s importance to patient safety. Offer them a chance to ask questions?
How to access the SMC list
know the changes and concentrations on the SMC list that are commonly used on your unit/ward
It is always important to share your knowledge and learning with your fellow colleagues by:
communicating and educating with them what you have learned – ensure that they have also taken this education you are receiving now
then lead by example by practicing and using the SCM list – we are all leaders! if you see that it is not being followed, you can encourage others to use it and help them to understand the patient safety importance of a SMC list. If pumps are not upgrade appropriately with the new drug library, please notify you biomed team for updates.
We understand that the change will be quite difficult initially and it may take some time to get use to, as we may not be use to mixing with the concentrations listed. But, think about the long term goals of what we are trying to achieve – patient safety and decrease the chances of errors.
Educate
Familiarize & Learn
Lead

22. Roll-out: April 1st, 2014 Parenteral Monographs Update Staff Training
March 3-7
March 10-14
March 17-21
March 24-28
March 31-April 4
April 7-11
April 14-18
April 21-25
April 28-May 2
May 5-9
April 1, 2014:
Smart Pump Drug Library Update & SMC List Available
RAH
UofA
Staff Training (provided by CNE)
PharmacyTraining
MCH
SMC Implementation
GNCH
Prior to roll-out of April 1st, 2014:
Parenteral Monographs Update
February – as new drugs monographs will be added on an ongoing basis; just make sure you are always using the online provincial monographs as they will automatically be updated there
Staff Training
March – encourage your fellow colleagues to take the training and help those around you (i.e. fellow colleagues and physicians) understand the importance of SMC and although it maybe a change at first, it will make a difference in the long run.
Smart Pump Drug Library Update
This will be done wirelessly on April 1st. There will be a memo that will be coming closer to the date with instructions on the procedure to update the pump. Important be aware and look for this memo
Smart Pump Software Upgrade
This will be a staggered upgrade during the month of April as this will require biomed technicians to come in and physically take the pumps off the units for the upgrade. Again, a memo will come out to update on how the process will look like.
During the week of:
March 31 – April 4  GNCH pumps will be upgraded
May 5-9  MCH pumps (this includes Villa Caritas) will be upgraded
Communication
Ongoing
Pre-printed Patient Care Orders (with non-standardized concentrations)
Training
Smart Pump Upgrade
Legend:

23. For More Information… Parenteral Monographs Smart Pump Library
Smart Pump Library
Policy and Procedures
Will be located on CompassionNet once finalized

24. Questions