High-Alert Medications in Acute Care Settings. Institute for Safe Medication Practices Institute for Healthcare Improvement. >> The 2018 publication reflects insights gathered through a survey of current medication use in acute care facilities. As a nurse faces prison for a deadly error, her colleagues worry: could I be next? In. %%EOF Institute for Safe MedicationPractices 5200 Butler Pike 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. In addition to insulin, anticoagulants, and opioids, high-alert. Free full text (PDF) Related news article ISMP list of confused drug names. writing, its high-alert and EP 1 hazardous medications. Additional Resources ASHP Center on Medication Safety and Quality Institute for Safe Medication Practices (ISMP) Manual: Behavioral Health . Additional Resources ASHP Center on Medication Safety and Quality Institute for Safe Medication Practices (ISMP) Manual: Ambulatory This may include strategies Plymouth Meeting, PA 19462. ISMP's List of High-Alert Medications in Acute Care Settings. Rockville, MD 20857 A clinical reminder about the safe use of insulin vials. Incorporating quality and safety values into a CLABSI simulation experience. Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis. Office-based physicians are responding to incentives and assistance by adopting and using electronic health records. magnesium sulfate injection. Annual Perspective: Psychological Safety of Healthcare Staff. 440,000 . You must have JavaScript enabled to use this form. A single risk-reduction strategy for each high-alert medication is rarely enough to prevent harmful errors. Sites, Contact In some cases, there are no safety nets in place at all, and hospitals are relying on staff vigilance to keep patients safe when receiving high-alert medications. This list may be used to determine redundancies such as automated or independent The hospitals high-alert medication list should be updated as needed and reviewed at least every 2 years. Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. /OPM 1 Safe Practice Recommendations: We encourage hospitals to take the time to reassess their current list of high-alert medications and any plans that have been enacted to reduce the risk of errors and harm with these drugs. 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. 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. Hospitals need a well-thought-out list of specific, high-alert medications and effective high-leverage processes to mitigate the risk of errors with these medications. Reporting medication errors: residents with diabetes. safety experts, ISMP created and periodically updates a list of potential high-alert medications. The current list includes new Best Practices on preventing errors with oxytocin and high-alert medications as well as maximizing the use of barcode verification by expanding beyond inpatient areas. 5600 Fishers Lane Telephone: (301) 427-1364. American Geriatrics Society (AGS) Policy Brief: COVID-19 and nursing homes. Use ISMP's List ofHigh-Alert Medications in Acute Care Settingsto determine which medications in your organization require special safeguards to reduce the risk of errors and minimize harm. /Type/XObject hbbd``b`I@UH @[ H8$~ 6.a$xfnH0X@ RObA6 bL3@b%3]X` The list will be informed by an environmental scan, consultation with Canadian health care practitioners, consumers, and their caregivers, and medication incidents reported to the Canadian Medication Incident Reporting and Prevention System (CMIRPS). Alice joined ISMP Canada in 2007 as a Medication Safety Specialist and received her BSc. Search All AHRQ 2023 Institute for Safe Medication Practices. https://www.ismp.org/recommendations/high-alert-medications-acute-list, Community/Ambulatory Setting: Learn more information here. October 1, 2021 Horsham, PA: Institute for Safe Medication Practices; 2021. below. Problem: Have you ever watched the 1993 movie, Groundhog Day? pediatrics) as high-alert can be effective as well. How often must a facility review the list of hazardous drugs contained in the facility? Specific Medications Car BAM azepine EPINEPH rine, IM, subcutaneous Insulin U-500 (special emphasis)* Lamo TRI gine Methotrexate, oral and parenteral, nononcologic use (special emphasis)* Phenytoin Valproic acid /Width 1022 2018. To be effective, all of these interdisciplinary components are needed: Understand the causes of errors. >> Sites, Contact 2012. Policies, HHS Digital risk of causing significant patient harm when Strategies for the effective management of high-alert medications include the following.*. Findings and Lessons From the AHRQ Ambulatory Safety and Quality Program. Accessed August 24, 2022. For example, after fatal wrong route errors were identified as a potential threat with the new drug EXPAREL (bupivacaine [liposomal] used for local anesthesia into surgical sites) due to its similar appearance to propofol,6 hospitals that added this drug to their formulary should have considered it for addition to their high-alert medication list. 2023 Institute for Safe Medication Practices. /Length 64894 Rockville, MD 20857 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. This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. /Type/ExtGState - direct oral anticoagulants and factor Xa inhibitors (e.g., dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, fondaparinux) - direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran) - glycoprotein IIb/IIIa inhibitors (e.g.,eptifibatide) - thrombolytics (e.g.,alteplase, reteplase, tenecteplase) cardioplegic solutions Moderate sedation agents, IV (eg, dexmedetomidine, midazolam, Moderate and minimal sedation agents, oral, for children (eg, chloral hydrate, midazolam, ketamine [using IV form]), Narcotics/opioids, IV, transdermal, oral (including liquid concentrates, immediate and sustained-release forms), Neuromuscular blocking agents (eg, succinylcholine, rocuronium, vecuronium), Sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers of 100mL or more, Sodium chloride for injection, hypertonic, greater than 0.9% concentration, Sulfonylurea hypoglycemics, oral (eg, chlorpro. Please select your preferred way to submit a case. 16.3% involved insulin products. Institute for Safe MedicationPractices 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. Explicit and Standardized Prescription Medicine Instructions. High-alert medications in long-term care include the following.*. . The purpose of identifying high-alert medications is to establish safeguards to reduce the risk of errors with these drugs in all phases of the medication use process. Only standardized concentrations, single dose containers shall be used. Another hospitalized patient experiencing pain receives an overdose of intravenous (IV) HYDROmorphone after a physician prescribes the IV dose in the same amount as the oral dose the patient had been taking at home, and neither the pharmacist nor nurse captures the error. How to cite: Institute for Safe Medication Practices (ISMP). 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. 5600 Fishers Lane Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. (Pharm.) This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors. 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? This important first step should not be skippedif you cant describe the ways that errors have happened or could happen with the drug, your strategies may not lessen the risk of an error at all. During June and July 2018, practitioners responded to an ISMP survey designed to identify which medications were most frequently considered high-alert medica - ti o ns.F u rh e, al v c d completeness, the clinical staff at ISMP and members of the ISMP advisory board . Addressing drugs given by a certain route of administration (e.g., intrathecal, epidural) or in special populations (e.g. /Height 237 Strategy, Plain such as standardizing the ordering, storage, To sign up for updates or to access your subscriber preferences, please enter your email address This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care. What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use. double-checks when necessary. 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. Electronic Policies, HHS Digital Annual Perspective: Topics in Medication Safety. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. During June and July 2018, practitioners responded to an ISMP survey designed to identify which drugs were most frequently considered high-alert medications by . Boldly label both sides of the infusion bag to differentiate oxytocin bags from plain hydrating solutions and magnesium infusions. Writing Act, Privacy ^N5#?frqtR ]tE}eb8kbd_>VI. That report showed that a majority of medication errors resulting in death or serious injury were caused by a specific list of medications. Safeguard against errors with oxytocin use. Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. endstream endobj 10 0 obj <> endobj 11 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC]/Properties<>/Shading<>/XObject<>>>/Rotate 0/TrimBox[0 0 612 792]/Type/Page/u2pMat[1 0 0 -1 0 792]/xb1 0/xb2 612/xt1 0/xt2 612/yb1 0/yb2 792/yt1 0/yt2 792>> endobj 12 0 obj <>stream One and Only Campaign. Note that even if you have an account, you can still choose to submit a case as a guest. Internal reporting system to improve a pharmacys medication distribution process. July 29, 2020 View More See More About Hospitals Health Care Providers Medicine Specific to High-Risk Drugs ISMP List of High-Alert Medications in Community/Ambulatory Healthcare Author: ISMP Subject: High-alert medications Created Date: 20110129135114Z . To learn the causes of errors, review internal medication error-reporting data and the results of any applicable root cause analyses. Please select your preferred way to submit a case. Institute for Safe Medication Practices. BackgroundIn 2012, the Institute for Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada) collaborated with an international panel of oncology pract. E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. ISMP List of High-Alert Medications in Community/Ambulatory Care Settings. Plymouth Meeting, PA 19462. 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. Get notified when a new bulletin is released. As a nurse faces prison for a deadly error, her colleagues worry: could I be next? Developing a principle-based approach to safe medication practices. Institute for Safe MedicationPractices Search All AHRQ So, what does it mean if a drug is on your hospitals high-alert medication list? Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. High-alert and Hazardous Medications . 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. ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. All rights reserved. Plymouth Meeting, PA 19462. 2. Plymouth Meeting, PA 19462. Services Medication List . 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