potential high-alert medications. endstream endobj startxref Safety considerations for challenges when using smart infusion pumps. Although mistakes may or may not be more common with these drugs, the consequences of an error with these medications are clearly more devastating to patients. American Geriatrics Society (AGS) Policy Brief: COVID-19 and nursing homes. How to cite: Institute for Safe Medication Practices (ISMP). 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. 1 0 obj The primary goals of implementing risk-reduction strategies are to: 1) prevent errors, 2) make errors visible, and 3) mitigate harm. This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. reduce the risk of errors. In 2003, during its first year of the Medication Safety Support Service (commissioned Equally important, a search of the external literature should be completed to uncover reports of errors with high-alert medications that have occurred elsewhere. An official website of ISMP List of High-Alert Medications in Community/Ambulatory Care Settings. 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. E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. Does the list serve only to increase awareness of the risk of harm with these medications, or has a robust plan been implemented for each drug or drug class to reduce the risk of errors? Internal reporting system to improve a pharmacys medication distribution process. That report showed that a majority of medication errors resulting in death or serious injury were caused by a specific list of medications. High-Alert Medications in Acute Care Settings. Sakowski J, Newman JM, Dozier K. Severity of medication administration errors detected by bar-code medication administration system. below. which medications require special safeguards to %PDF-1.4 insulins. This initiative will help address recommendations from the Gillese Inquiry, including strengthening medication management to deter and detect intentional and unintentional harm in homes. Horsham, Pa.Reflecting on the 20-year anniversary of the watershed Institute of Medicine report To Err Is Human, the Institute for Safe Medication Practices (ISMP) has published a "top ten" list of the most persistent medication errors and safety issues covered in its newsletter in 2019.The list focuses on safety problems that are frequently reported, caused serious harm to patients . 5200 Butler Pike Of those reports: 44% involved pain management medications including morphine, hydromorphone (DILAUDID), meperidine (DEMEROL) and fentanyl. nitroprusside sodium for injection. Office-based physicians are responding to incentives and assistance by adopting and using electronic health records. Note that even if you have an account, you can still choose to submit a case as a guest. Maximize the use of barcode verification prior to medication and vaccine administration by expanding use beyond inpatient care areas. 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). Horsham, PA: Institute for Safe Medication Practices; 2021. The update includes changes such as expanded examples of antithrombotic agents listed and removal of IV radiocontrast media due to lack of errors reported with its use. To learn more about Liked by Avo Arikian, Pharm.D. 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. Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. Strategies for the effective management of high-alert medications include the following.*. How often must a facility review the list of hazardous drugs contained in the facility? Please select your preferred way to submit a case. ISMP began issuing Best Practices in 2014. Another woman receives a rapid infusion of magnesium sulfate postpartum instead of oxytocin, despite staff awareness of prior mix-ups. 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. The organization identifies, in writing, its high -alert and hazardous medications . Accessed August 24, 2022. High-Alert Medication Learning Guides for Consumers. Although targeted for the hospital setting, they can be applicable to other areas of healthcare as well.. 1. Insulin U-500 has been singled out for special emphasis to bring attention to the need for distinct strategies to prevent the types of errors that occur with this concentrated form of insulin. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. 2023 Institute for Safe Medication Practices. 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 . DAW is dispense as written and are used for brand name medication; AWP is average wholesale price and is the price the wholesalers sell a medication; MAC is maximum allowable cost is used in calculating the reimbursement formula for generic medication. Limit the use of independent double checks to select high-alert medications with the greatest risk for error within the organization. consequences of an error are clearly more devastating for all of the medications on the list). Only standardized concentrations, single dose containers shall be used. 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). Reporting medication errors: residents with diabetes. double-checks when necessary. pediatrics) as high-alert can be effective as well. 0 Require the use of standard order sets for prescribing oxytocin antepartum and/or postpartum that reflect a standardized clinical approach to labor induction/augmentation and control of postpartum bleeding. In many cases, events like these and others continue to happen in hospitals with medications that are on the hospitals list of high-alert 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 individuals and organizations. Use ISMP'sList ofHigh-Alert Medications in Community/Ambulatory Care Settingsto determine which medications in your practice site require special safeguards to reduce the risk of errors and minimize harm. stream Strategy, Plain For example, a May 2017 ISMP safety bulletin featured an unfortunate medication incident which led to the death of a patient from dispensing the incorrect medication. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Copyright 2000-2023 Institute for Safe Medication Practices Canada (ISMP Canada). /BitsPerComponent 8 During February-April 2007, 770 practitioners responded to an ISMP survey designed to identify which of these medications were most frequently consid-ered high-alert drugs by individuals and organizations. Identifying potential medication discrepancies during medication reconciliation in the post-acute long-term care setting. A single risk-reduction strategy for each high-alert medication is rarely enough to prevent harmful errors. The Joint Commission has a standard (MM.01.01.03) that requires hospitals to develop their own list of high-alert medications; to have a process for managing high-alert medications; and to implement that process. Other drugs from the ISMP list should be added if use is prevalent or misuse is a concern. ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. Rockville, MD 20857 Writing Act, Privacy What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. The in-use time for a multidose container is an ISO 5 environment . Patient safety perceptions of primary care providers after implementation of an electronic medical record system. potassium phosphates injection. 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. Institute for Safe MedicationPractices Strategies for optimizing OR drug safety. Drug name pairs or larger groupings that look similar utilize bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. Standardize how oxytocin doses, concentration, and rates are expressed. opioids. Plymouth Meeting, PA 19462. The new Best Practices that have been added for 2022-2023 are: OXYTOCIN BEST PRACTICE: Antibiotics c. Chemotherapeutic agents d. . 5200 Butler Pike Policies, HHS Digital Antithrombotic agents, oral and parenteral, including: Anticoagulants (e.g., warfarin, low molecular weight heparin, unfractionated heparin), Direct oral anticoagulants and factor Xa inhibitors (e.g., dabigatran, rivaroxaban, apixaban, edoxaban), Direct thrombin inhibitors (e.g., dabigatran), Oral and parenteral chemotherapy (e.g., capecitabine, cyclophosphamide), Oral targeted therapy and immunotherapy (e.g., palbociclib [IBRANCE], imatinib [GLEEVEC], bosutinib [BOSULIF]), Immunosuppressant agents, oral and parenteral (e.g., azaTHIOprine, cycloSPORINE, tacrolimus), Insulins, all formulations and strengths (e.g., U-100, U-200, U-300, U-500), Medications contraindicated during pregnancy (e.g., bosentan, ISOtretinoin), Moderate and minimal sedation agents, oral, for children (e.g., chloral hydrate, midazolam, ketamine [using the parenteral form]), Opioids, all routes of administration (e.g., oral, sublingual, parenteral, transdermal), including liquid concentrates, immediate- and sustained-release formulations, andcombination products with another drug, Pediatric liquid medications that require measurement, Sulfonylurea hypoglycemics, oral (e.g., chlorproPAMIDE, glimepiride, glyBURIDE, glipiZIDE, TOLBUTamide), Methotrexate, oral and parenteral,nononcologic use (special emphasis)*. annual review). Start the year off right by addressing these top 10 medication safety concerns from 2021. National Alert Network. Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. Policies, HHS Digital Develop your own list based on unique utilization patterns and internal data about medication errors and sentinel events High-alert and hazardous medications & look-alike/sound-alike (LASA) medications in the ambulatory setting MM 01.01.03 vs MM 01.02.01 The organization safely manages Medication adverse events in the ambulatory setting: a mixed-methods analysis. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. During June and July 2018, practitioners responded to an ISMP survey designed to identify which drugs were most frequently considered high-alert medications by individuals and organizations. chemotherapeutic agents. 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