preparation, and administration of these products; 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. chemotherapeutic agents. Further, to assure relevance and completeness, the clinical staff at ISMP and members of the ISMP advisory board were asked to review the potential list. << ISMP's List of High-Alert Medications in Acute Care Settings. Cohen MR, Smetzer JL, Tuohy NR, et al. NCPS promotes three principles to improve high-alert medication administration and distribution: .'5;gE/Pc'~A^eq?Lm9Sb ysZ8:oi'w9LnNL7:L.iYfc$RjmfPm]u_\x Another hospitalized patient experiencing pain receives an overdose of intravenous (IV) HYDROmorphone after a physician prescribes the IV dose in the same amount as the oral dose the patient had been taking at home, and neither the pharmacist nor nurse captures the error. You must be logged in to view and download this document. ISMP has identified the top 10 medication safety issues of 2021, and mix-ups with COVID vaccines are at the head of the list. for all of the medications on the list). /ColorSpace/DeviceCMYK This is repeatedly borne out in the literature1-5 and by reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP). hbbd``b`I@UH @[ H8$~ 6.a$xfnH0X@ RObA6 bL3@b%3]X` potential high-alert medications. How to cite: Institute for Safe Medication Practices (ISMP). Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. potassium chloride for injection concentrate. 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. 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). . Numerous risk-reduction strategies must be layered together to address the targeted risk. Us. 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? Alice is involved in medication safety, medication reconciliation, incident analysis and has a passion for engaging patients and . . Table A: High-Alert List (Adapted from ISMP US) Medication Class/ Category Medication Examples Rationale for Inclusion: Anticoagulants, oral and . Worksheet for the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals30 Worksheet for the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals 30 This tool was developed to assist hospitals in analyzing their current status with implementing the 202 2 -202 3 ISMP Targeted M edic at ion Safe t y B es t Prac t Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. Safety considerations for challenges when using smart infusion pumps. A clinical reminder about the safe use of insulin vials. 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 . Majority of Survey Respondents Agree Tall Man Lettering Helps Prevent Errors, ECRIs report warns of potential safety risks with 10 health technologies, including single-use products, medication cabinets, cybersecurity of cloud-based systems, and ventilator disinfection. Although mistakes may Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients. Department of Health & Human Services. ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. Sites, Contact Patient safety perceptions of primary care providers after implementation of an electronic medical record system. Rickrode GA, Williams-Lowe ME, Rippe JL, et al. Maximize the use of barcode verification prior to medication and vaccine administration by expanding use beyond inpatient care areas. High-alert medications are drugs that bear a heightened 5600 Fishers Lane Relationship of adverse events and support to RN burnout. In total, 14 medications and 4 medication classes were included with the predefined level of consensus of 75%. w !1AQaq"2B #3Rbr ISMP list of confused drug names. Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications. /Length 64894 So, what does it mean if a drug is on your hospitals high-alert medication list? Please select your preferred way to submit a case. The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study. 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. All rights reserved. (Note: manual independent double-checks are not always the optimal Some high-alert medications also have a high volume of use, increasing the likelihood that a patient might suffer inadvertent harm. opioids. or may not be more common with these drugs, the Source: Institute for Safe Medication Practices. Get notified when a new bulletin is released. Though medication mishaps with these drugs are no more frequent than other drugs, the consequences can be devastating. Note that even if you have an account, you can still choose to submit a case as a guest. 5200 Butler Pike 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 . 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). /Type/XObject This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. 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. Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing. Institute for Safe Medication Practices. Strategy, Plain Annual Perspective: Psychological Safety of Healthcare Staff. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices. Further, to assure relevance below. >> Medication adverse events in the ambulatory setting: a mixed-methods analysis. parenteral nutrition preparations. 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. 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. Annual Perspective: Topics in Medication Safety. While most facilities meet the minimum requirements for The Joint Commission (i.e., any list, any process), some hospitals have neither a well-reasoned list of high-alert medications nor a robust set of processes for managing the high-alert medications on their list. Strategy, Plain Acetic acid irrigant is administered _____ Intravesical. Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety. /OPM 1 ), High-Alert Medications in Community/Ambulatory Care Settings, High-Alert Medications in Long-Term Care (LTC) Settings, Look-Alike Drug Names with Recommended Tall Man (Mixed Case) Letters, Medication Safety Officers Society (MSOS), adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol), anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine), antiarrhythmics, IV (e.g., lidocaine, amiodarone), chemotherapeutic agents, parenteral and oral, dialysis solutions, peritoneal and hemodialysis, inotropic medications, IV (e.g., digoxin, milrinone), liposomal forms of drugs (e.g., liposomal amphotericin B) and conventional counterparts (e.g., amphotericin B desoxycholate). Engaging Patients in Improving Ambulatory Care. Nurses' communication of safety events to nursing home residents and families. ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. 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. Exclamation point icon identifies ISMP high-alert drugs. 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. FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters. This Ethical Issues . Its approximately what you craving currently. ISMP List of High-Alert Medications in Community/Ambulatory Care Settings. Accessed August 24, 2022. https://www.ismp.org/recommendations/high-alert-medications-community-ambulatory-list, Long-Term Care Setting: 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. 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. Reporting medication errors: residents with diabetes. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Unintended patient safety risks due to wireless smart infusion pump library update delays. 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. Note that even if you have an account, you can still choose to submit a case as a guest. Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies. 5200 Butler Pike Please select your preferred way to submit a case. Standardizing the ordering, storage, preparation, and administration of these . Institute for Safe MedicationPractices Standardize to a single concentration/bag size for both antepartum and postpartum oxytocin infusions (e.g., 30 units in 500 mL Lactated Ringers). . High-alert medications: the safeguards that you should put in place to reduce risks. ISMP has issued its 2022-2023 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 despite repeated warnings in ISMP publications. Note that even if you have an account, you can still choose to submit a case as a guest. 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. Rockville, MD 20857 All rights reserved. Strategies for optimizing OR drug safety. ISMP List of High-Alert Medications in Community/Ambulatory Healthcare Author: ISMP Subject: High-alert medications Created Date: 20110129135114Z . 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. August 23, 2018 Horsham, PA; Institute for Safe Medication Practices: 2018. Developing a principle-based approach to safe medication practices. Institute for Safe MedicationPractices Plymouth Meeting, PA 19462. stream 2018. 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. The effects of electronic prescribing by community-based providers on ambulatory medication safety. 2013 Feb 21;18(4);1-4. This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors. At the head of the list and download this document the medications on the.... By community-based providers on ambulatory medication safety and weaknesses of electronic prescribing by community-based providers ambulatory... Of these Relationship of adverse events involving opioid overdoses in the ambulatory setting: a database... Record system root cause analysis of adverse events and support to RN burnout they used... 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