Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications. /Height 237 insulins. Insulin pen safety - one insulin pen, one person. Strategies for the effective management of high-alert medications include the following.*. Findings and Lessons From the AHRQ Ambulatory Safety and Quality Program. redundancies such as automated or independent C ISMP List of High-Alert Medications in Acute Care Settings. Annually. Standardize to a single concentration/bag size for both antepartum and postpartum oxytocin infusions (e.g., 30 units in 500 mL Lactated Ringers). 2013 Feb 21;18(4);1-4. 2023 Institute for Safe Medication Practices. The IHS is the principal federal health care provider and health advocate for Indian people, and provides a comprehensive health service delivery system for American Indians and Alaska Natives. 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. ISMP began issuing Best Practices in 2014. 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 chemotherapeutic agents. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. /Width 1022 American Geriatrics Society (AGS) Policy Brief: COVID-19 and nursing homes. 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. Though medication mishaps with these drugs are no more frequent than other drugs, the consequences can be devastating. The hospital may also send memos to staff to increase their awareness of the risks or establish strategies that impact only one aspect of the medication use processusually drug storage. Regularly review compliance and other metric data to assess utilization and effectiveness of this safety technology (e.g., scanning compliance rates; bypassed or acknowledged alerts). High-alert drugs are those with an increased risk for causing patient harm, especially when used incorrectly. /BitsPerComponent 8 magnesium sulfate injection. below. https://www.ismp.org/recommendations/high-alert-medications-acute-list, https://www.ismp.org/recommendations/high-alert-medications-community-ambulatory-list, https://www.ismp.org/recommendations/high-alert-medications-long-term-care-list. Avoid reliance on low-leverage risk-reduction strategies (e.g., applying high-alert medication labels on pharmacy storage bins, providing education) to prevent errors, and instead bundle these with mid- and high-leverage strategies. The hospitals high-alert medication list should be updated as needed and reviewed at least every 2 years. Engaging Patients in Improving Ambulatory Care. High-Alert Medications in Acute Care Settings. You must have JavaScript enabled to use this form. Please select your preferred way to submit a case. potassium chloride for injection concentrate. Very few studies have been conducted involving medications commonly used in Boldly label both sides of the infusion bag to differentiate oxytocin bags from plain hydrating solutions and magnesium infusions. Additional Resources ASHP Center on Medication Safety and Quality Institute for Safe Medication Practices (ISMP) Manual: Behavioral Health 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. >> 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. 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 This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. 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. All rights reserved. 2012. 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. 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? Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice. 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. Telephone: (301) 427-1364. A past PSNet perspective discussed medication safety in nursing homes. Rockville, MD 20857 oxytocin, IV. 2023 Institute for Safe Medication Practices. Effectiveness of double checking to reduce medication administration errors: a systematic review. Note that even if you have an account, you can still choose to submit a case as a guest. High-alert medications: safeguarding against errors. Telephone: (301) 427-1364. 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). To sign up for updates or to access your subscriber preferences, please enter your email address /Filter/DCTDecode Source: Institute for Safe Medication Practices. Exclamation point icon identifies ISMP high-alert drugs. 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 . Identifying potential medication discrepancies during medication reconciliation in the post-acute long-term care setting. The hospital's high-alert medication list should be updated as needed and reviewed at least every 2 years. to patients. Although targeted for the hospital setting, they can be applicable to other areas of healthcare as well.. 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. Please select your preferred way to submit a case. The 2018 publication reflects insights gathered through a survey of current medication use in acute care facilities. } !1AQa"q2#BR$3br All rights reserved. Medication safety in primary care practice: results from a PPRNet quality improvement intervention. error-reduction strategy and may not be practical study, administration of the high-alert medications described by ISMP has been shown to be a risk factor for harm in neonatal patients (Stavroudis et al., 2010). Institute for Safe MedicationPractices The primary goals of implementing risk-reduction strategies are to: 1) prevent errors, 2) make errors visible, and 3) mitigate harm. ISMP Publishes 2020-2021 Consensus-Based Medication Safety Best Practices for Hospitals ISMP issued its 2020-2021 Targeted Medication Safety Best Practices for Hospitals to help identify, inspire, and mobilize widespread national action to address recurring problems that continue to cause fatal and harmful errors The Ministry of Long-Term Care (MLTC) in Ontario is partnering with ISMP Canada for 3 years to support long-term care homes in strengthening medication safety. Long-term care patients often have concurrent conditions that increase their risk of medication error. 1 0 obj Acute Care Setting: In addition, five best practices were archived this year or incorporated into other items. That report showed that a majority of medication errors resulting in death or serious injury were caused by a specific list of medications. Policy, U.S. Department of Health & Human Services. 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. preparation, and administration of these products; You must have JavaScript enabled to use this form. writing, its high-alert and EP 1 hazardous medications. 5600 Fishers Lane The new Best Practices that have been added for 2022-2023 are: OXYTOCIN BEST PRACTICE: Should I report? Worklife balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis. << Table A: High-Alert List (Adapted from ISMP US) Medication Class/ Category Medication Examples Rationale for Inclusion: Anticoagulants, oral and . Acetic acid irrigant is administered _____ Intravesical. The Institute for Safe Medication Practices (ISMP) estimates that around _____ deaths per year are linked to actual medication errors. Nursing Interventions Classification (NIC) - Gloria M. Bulechek . CMIRPS (Note: manual independent double-checks are not always the optimal 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. From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. Free full text (PDF) Related news article * All forms of insulin, SC and IV, are considered high-alert medications. Products with Medication Guides; Narrow Therapeutic Index Drugs; Products with REMS; Package Requires Dilution; Boxed Warning Monographs; Acute High Alert ISMP; Community/Ambulatory High Alert ISMP; Products by Manufacturer Patient safety perceptions of primary care providers after implementation of an electronic medical record system. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Copyright 2000-2023 Institute for Safe Medication Practices Canada (ISMP Canada). 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. Sakowski J, Newman JM, Dozier K. Severity of medication administration errors detected by bar-code medication administration system. Products with Medication Guides; Narrow Therapeutic Index Drugs; Products with REMS; Package Requires Dilution; Boxed Warning Monographs; Acute High Alert ISMP; Community/Ambulatory High Alert ISMP; Products by Manufacturer Cohen MR, Smetzer JL, Tuohy NR, et al. During June and July 2018, practitioners responded to an ISMP survey designed to identify which drugs were most frequently considered high-alert medications by . 5200 Butler Pike First published date: September 25, 2017 . created and periodically updates a list of potential high-alert medications. High-alert medications in long-term care include the following.*. To assure relevance and completeness, the clinical staff at ISMP, members of ISMPs community/ambulatory care advisory board, and other safety and clinical experts in the US were asked to review the list and potential changes. 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