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. %PDF-1.4 The five "high-alert medications" are as follows: 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. 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. The hospital's high-alert medication list should be updated as needed and reviewed at least every 2 years. hbbd``b`I@UH @[ H8$~ 6.a$xfnH0X@ RObA6 bL3@b%3]X` The Joint Commission recommends strategies such as a system that confirms the correct drug, dosage, patient, time, and route. This current list reflects the collective thinking of all who provided input. 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. Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the humancomputer interaction. May 17, 2021 User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study. A high-alert medication (HAM), is a medication that carries a heightened risk of causing significant harm if it's used in error. All Rights Reserved. Should I report? Effective strategies must address the underlying causes of errors with each type of high-alert medication or class of medications. 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. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Communicate orders for oxytocin infusions in terms of the dose rate (e.g., milliunits/minute) and align with the smart infusion pump dose error-reduction system (DERS). For a copy of the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals, visit: https://www.ismp.org/resources/three-new-best-practices-2022-2023-targeted-medication-safety-best-practices-hospitals. preparation, and administration of these products; How often must a facility review the list of hazardous drugs contained in the facility? Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters. Developing a principle-based approach to safe medication practices. The medication safety pharmacist is responsible for managing medication use safety and improvement plans. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Policies, HHS Digital This Ethical Issues . High-Alert Medications in Long-Term Care (LTC) Settings, High-Alert Medications in Acute Care Settings, Look-Alike Drug Names with Recommended Tall Man (Mixed Case) Letters, Medication Safety Officers Society (MSOS). Although many medications on ISMP's current list, such as oral hypoglycemic agents, insulin, and opioids, would be considered high alert in all environments, a similar list has never existed specifically for community and ambulatory care settingsuntil now. Although it is important to improve management of all of these medications, some of them have been associated more frequently with harm, such as anticoagulants, narcotics and opiates, insulins, and sedatives. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. Assistance with implementation of an antiretroviral screening tool upon admission to prevent adverse drug events. This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. All forms of insulin, subcutaneous and IV, are considered a class of high-alert medications. chemotherapeutic agents. 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. %%EOF Plymouth Meeting, PA 19462. 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 . Note that even if you have an account, you can still choose to submit a case as a guest. . Please select your preferred way to submit a case. May 17, 2021 Horsham, PA: Institute of Safe Medication Practices; 2021 Long-term care patients often have concurrent conditions that increase their risk of medication error. The Institute for Safe Medication Practices (ISMP) High-Alert Medications [Box 1.3] Pregnancy Categories for Safety Beers Criteria - NOT APPROPRIATE FOR ANYONE ABOVE 65 Types of Medication Prescriptions Routine or standing Single or one-time STAT " Immediately " - legally we have a half hour PRN " as needed " AD LIB - use as . Institute for Safe Medication Practices. Institute for Safe MedicationPractices ISMP National Medication Errors Reporting Program, Medication Safety Officers Society (MSOS). Based on error reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP), reports of harmful errors in the literature, studies that identify the drugs most often involved in harmful errors, and input from practitioners and safety experts, ISMP created and has periodically updated a list of high-alert medications in community and ambulatory care settings. Hospital medication errors: a cross sectional study. As a nurse faces prison for a deadly error, her colleagues worry: could I be next? Please login or register first to view this content. magnesium sulfate injection. The 2018 publication reflects insights gathered through a survey of current medication use in acute care facilities. ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. a. Antiarrhythmics b. A prospective observational 2017 study evaluating high-risk medication errors in hospital-admitted diabetes patients found that clinical pharmacists identified 3,947 (100%) of medication discrepancies.7 Of these errors, pharmacists caught 2,676 errors for 904 patients upon admission, and identified 1,271 discrepancies for the 865 who completed . A clinical reminder about the safe use of insulin vials. (Pharm.) Policies, HHS Digital to patients. Links to resources for identifying high -risk medications can be found in Chapter 5 of this manual . 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. Anticoagulants (eg, warfarin, low-molecular-weight heparin, unfractionated heparin), Direct oral anticoagulants and Factor Xa inhibitors (eg, dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, fondaparinux), Direct thrombin inhibitors (eg, argatroban, bivalirudin, dabigatran), Thrombolytics (eg, alteplase, reteplase, tenecteplase), Glycoprotein IIb/IIIa inhibitors (eg, eptifibatide). High-risk medications used in the NICU, modified from the ISMP high-alert medication list are in a Table 1. potassium chloride for injection concentrate. This may include strategies Table A: High-Alert List (Adapted from ISMP US) Medication Class/ Category Medication Examples Rationale for Inclusion: Anticoagulants, oral and . parenteral nutrition preparations. Strategies may include: Standardizing the prescribing, storage, preparation, dispensing, and administration of these medications, Improving access to information about these drugs, Using auxiliary labels and automated alerts. The Best Practices address safety issues that ISMP continues to receive numerous reports about, says Christina Michalek, BS, RPh, FASHP, Medication Safety Specialist and Administrative Coordinator for the Medication Safety Officers Society (MSOS). 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. ISMP's List of High-Alert Medications in Acute Care Settings. 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. One and Only Campaign. Worklife balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis. Nursing home patient safety culture perceptions among US and immigrant nurses. Similar findings were found in an ISMP study, the 1996 Benchmarking Project, which culled data on serious medication errors from 161 health care organizations. The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study. reduce the risk of errors. Long-Term Trends of Psychotropic Drug Use in Nursing Homes. Bill Murray plays Phil Conners, a television news reporter who finds himself reliving the same day over and over againa much-hated assignment covering the annual Groundhog Day event in Punxsutawney, PA. Well, at times it feels like Groundhog Day when we hear about the same types of errors happening over and over again. National Alert Network. You must be logged in to view and download this document. Please select your preferred way to submit a case. High-alert medications: safeguarding against errors. . 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