1. Managing Hospital Safety: Common Safety Concerns (Hospital-focused presentation) Part 3 of 4

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

3. High-Alert Medications: A Cause for Concern Why Are High-Alert Medications a Cause For Concern? More likely to be associated with harm than other medications Harm leads to poor outcomes for patients and increased patient care costs Cause harm more commonly and the harm produced is likely more serious Institute for Healthcare Improvement (IHI). Getting started kit: prevent harm from high-alert medications. http://www.ihi.org. Accessed January 29, 2009.

4. Medications Associated With the Highest Risk of Injury When Misused Are Known as High-Alert Medications 1 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 ISMP 1 IHI 2 Joint Commission 3 Parenteral chemotherapyAnticoagulantsInsulin IV insulinNarcotics and opiatesOpiates and narcotics Potassium chlorideInsulin Injectable potassium chloride or phosphate concentrate IV unfractionated heparinSedativesIV anticoagulants Epidural/intrathecal drugs Sodium chloride solutions >0.9%

5. 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.

6. Examples of ISMP Medication Safety Recommendations for Hospitals Many recommendations address the common risk factors for high-alert medications: – Process 1 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.

7. Examples of ISMP Medication Safety Recommendations for Hospitals (cont’d) Many recommendations address the common risk factors for high-alert medications: – Medication administration 1 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.

8. Examples of ISMP Medication Safety Recommendations for Hospitals (cont’d) Medication administration 1 (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.

9. Managing Hospital Safety: Focus on Insulin

10. Increased Hospital Safety Concerns 1-3 High-Alert Medications (JCAHO) 1 1. Insulin 2. Opiates and narcotics 3. Injectable potassium chloride or phosphate concentration 4. IV anticoagulants 5. 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.

11. Insulin Errors Directly Affect Inpatient Care Insulin is a major contributor of injury-induced medication errors within the hospital setting 1 Per Institute for Safe Medication Practices (ISMP), 11% of serious medication errors were associated with incorrect insulin administration 2 Insulin may be twice as likely to cause patient harm vs other reported medications based on MEDMARX data compiled by United States Pharmacopeia 3 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.