endstream endobj startxref Among medication error reports submitted to PA-PSRS, approximately one out of four reports involve high-alert medications. Internal reporting system to improve a pharmacys medication distribution process. 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 . I knew if I wanted to become a subject matter expert and advance through the ranks of medication safety specialists, I needed to align myself with the organization considered the gold standard for medication safety information. Long-Term Trends of Psychotropic Drug Use in Nursing Homes. ISMP Med Saf Alert Acute Care. Consultations will begin soon, but practitioners, consumers, and their caregivers can begin to contribute to the Canadian list by: Practitioners looking for existing resources on high-alert medications can review the lists developed by the Institute for Safe Medication Practices in the United States. Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies. Based on error reports submitted to the Institute of Safe Medication Practices (ISMP) National Medication Errors Reporting Program, reports of harmful errors in the literature, and input from practitioners and safety experts, ISMP created and periodically updates a list of potential high-alert medications. As a nurse faces prison for a deadly error, her colleagues worry: could I be next? 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. Strategies may include: How to cite:Institute for Safe Medication Practices (ISMP). All rights reserved. Annual Perspective: Topics in Medication Safety. w !1AQaq"2B #3Rbr Plymouth Meeting, PA 19462. or may not be more common with these drugs, the When implementing strategies, there must be a balance on how resources will be impacted by the change. Horsham, PA; Institute for Safe Medication Practices: 2018. ISMP; 2021. reduce the risk of errors. (e.g., chemotherapy, opioid infusions, intravenous [IV] insulin, heparin infusions). High-alert medications: the safeguards that you should put in place to reduce risks. 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. insulins. 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 . https://www.ismp.org/recommendations/high-alert-medications-acute-list, Community/Ambulatory Setting: Plymouth Meeting, PA 19462. - 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 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. Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing. Information distortion in physicians' diagnostic judgments. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Sites, Contact 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). 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. 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. Many hospitals select medications from ISMPs List of High-Alert Medications, which is updated every few years based on error reports submitted to the ISMP National Medication Errors Reporting Program, reports of harmful errors in the literature, and input from practitioners and safety experts.4 Based on national reports of harm to patients, we believe it is essential for every hospitals list to include (when used): concentrated electrolytes, neuromuscular blocking agents, opioids (all, not just patient-controlled analgesia), anticoagulants, insulin, epidural or intrathecal medications, and chemotherapy. American Geriatrics Society (AGS) Policy Brief: COVID-19 and nursing homes. 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. 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. writing, its high-alert and EP 1 hazardous medications. 2013 Feb 21;18(4);1-4. Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the humancomputer interaction. Problem: Have you ever watched the 1993 movie, Groundhog Day? 5600 Fishers Lane C document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Copyright 2000-2023 Institute for Safe Medication Practices Canada (ISMP Canada). All forms of insulin, subcutaneous and IV, are considered a class of high-alert medications. the 1. The list of high-alert medications includes as many as 19 categories and 14 specific medications. 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. 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 . Telephone: (301) 427-1364. Which of the following drug classifications is not listed on the ISMP List of High-Alert drug Classes or Categories of mediciatons? High-alert drugs are those with an increased risk for causing patient harm, especially when used incorrectly. Reporting medication errors: residents with diabetes. hypoglycemics. To update the list, practitioners were once again surveyed. /ColorSpace/DeviceCMYK 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 High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. In 2003, during its first year of the Medication Safety Support Service (commissioned Source: Institute for Safe Medication Practices. Reviewing the effectiveness of safeguards and extending the reach of all your risk-reduction strategies are important to ongoing success within your organization. How to cite: Institute for Safe Medication Practices (ISMP). ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. 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. 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. 37 0 obj <>/Filter/FlateDecode/ID[<511D81E4C823079F14A719C2AEE68921><940396CC49DB344DBB373A7EAC1C47A0>]/Index[9 120]/Info 8 0 R/Length 123/Prev 61533/Root 10 0 R/Size 129/Type/XRef/W[1 2 1]>>stream The in-use time for a multidose container is an ISO 5 environment . Get notified when a new bulletin is released. %PDF-1.4 https://www.ismp.org/recommendations/high-alert-medications-community-ambulatory-list, Long-Term Care Setting: Standardize how oxytocin doses, concentration, and rates are expressed. October 1, 2021 Horsham, PA: Institute for Safe Medication Practices; 2021. Please select your preferred way to submit a case. A high-alert medication (HAM), is a medication that carries a heightened risk of causing significant harm if it's used in error. 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. Only standardized concentrations, single dose containers shall be used. 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)*. Sites, Contact 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). Worklife balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis. 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. Exclamation point icon identifies ISMP high-alert drugs. Policies, HHS Digital potential high-alert medications. 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. and high alert medications as such Separate the storage of such items in the carts Verify, re-verify and triple check before giving medications, especially high alert medications - the six rights can help, but may not prevent errorsmore than this is required. 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. This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors. ISMP website High-Alert Medications High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. error-reduction strategy and may not be practical Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes. Although targeted for the hospital setting, they can be applicable to other areas of healthcare as well.. The high-alert medications were: amiodarone, digoxin, dopamine, epinephrine, fentanyl, gentamycin, heparine, insulin, morphine, norepinephrine, phenytoin, potassium, propofol and tacrolimus. In addition, five best practices were archived this year or incorporated into other items. This list may be used to determine 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. Improving medication administration safety: using nave observation to assess practice and guide improvements in process and outcomes. Developing a principle-based approach to safe medication practices. Writing Act, Privacy Engaging Patients in Improving Ambulatory Care. M(#iueno9Q!6G5^1Ai~Qk1+jh ]T*RA#ZnAE:q"h V.d9#uG[roh+^GV[sab4C19}K7^+@{ym8U~nM+S#B_h~OI)UOx &%Eg*5wk:SJ^IU f#*`>I:koQ%R8jk9I~/$O|AOJ_=5x,/ JFIF Adobe e C 2012. Links to resources for identifying high -risk medications can be found in Chapter 5 of this manual . The organization follows a process for managing high-alert and hazardous medications . To assure relevance and completeness, the clinical staff at ISMP, members of ISMPs community/ambulatory care advisory board, and other safety and clinical experts in the US were asked to review the list and potential changes. Strategies must be sustainable over time. May 17, 2021 Horsham, PA: Institute of Safe Medication Practices; 2021 Long-term care patients often have concurrent conditions that increase their risk of medication error. Additional Resources ASHP Center on Medication Safety and Quality Institute for Safe Medication Practices (ISMP) Manual: Home Care Unintended patient safety risks due to wireless smart infusion pump library update delays. Rockville, MD 20857 ISMP List of High-Alert Medications in Community/Ambulatory Healthcare Author: ISMP Subject: High-alert medications Created Date: 20110129135114Z . A clinical reminder about the safe use of insulin vials. The five "high-alert medications" are as follows: Work-arounds observed by fourth-year nursing students. hbbd``b`I@UH @[ H8$~ 6.a$xfnH0X@ RObA6 bL3@b%3]X` << Medication administration and interruptions in nursing homes: a qualitative observational study. ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. HIGH-ALERT MEDICATION SAFETY BEST PRACTICE: 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). improving access to information about these drugs; ISMP National Medication Errors Reporting Program, Medication Safety Officers Society (MSOS). These specific medications have been singled out for special emphasis to bring attention to the need for distinct strategies to prevent the types of errors that occur with these medications. Sites, Contact created and periodically updates a list of potential high-alert medications. Magnesium Sulfate Injection. To learn more about Liked by Avo Arikian, Pharm.D. 16.3% involved insulin products. Rockville, MD 20857 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 ISMP List of High-Alert Medications in Acute Care Settings. Diamond icons indicate key drugs in the Dosage tables. 2023 Institute for Safe Medication Practices. Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. 14.2% involved heparin. ISMP Canada is developing a Canadian list of high-alert medications. Advanced practice nursing students' identification of patient safety issues in ambulatory care. Are as follows: Work-arounds observed by fourth-year nursing students developing a Canadian list of high-alert Classes. 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