Rockville, MD 20857 Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies. 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. to patients. 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. 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. Manual: Ambulatory Chapter: Medication Management MM Last reviewed by Standards Interpretation: October 19, 2021 Represents the most recent date that the FAQ was reviewed (e.g. 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 . The third new ISMP best practice suggests that providers layer numerous strategies throughout the medication-use process to improve safety with high-alert medications. Doing right by our patients when things go wrong in the ambulatory setting. NEW! ISMP; 2021. 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. Please select your preferred way to submit a case. ^N5#?frqtR ]tE}eb8kbd_>VI. The list of high-alert medications includes as many as 19 categories and 14 specific medications. Exclamation point icon identifies ISMP high-alert drugs. Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. Institute for Safe MedicationPractices 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. Rockville, MD 20857 5200 Butler Pike chemotherapeutic agents. Of those reports: 44% involved pain management medications including morphine, hydromorphone (DILAUDID), meperidine (DEMEROL) and fentanyl. Plymouth Meeting, PA 19462. writing, its high-alert and EP 1 hazardous medications. below. Telephone: (301) 427-1364. 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 material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. The organization identifies, in writing, its high -alert and hazardous medications . The following list of specific high-alert medications come form the ISMP. Alice is involved in medication safety, medication reconciliation, incident analysis and has a passion for engaging patients and . This list of medications and drug categories reflects the collective thinking of all who provided input. For each medication on the facilitys high-alert medication list, outline a robust set of processes for managing risk, impacting as many steps of the medication-use process as feasible. 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. /Type/XObject Source: Institute for Safe Medication Practices. Electronic medical record availability and primary care depression treatment. hb``b``c [NY8!O8`SxKlIlhGe!0nZ !|, P %%EOF They are designed to set realistic goals, which have already been adopted by numerous organizations. Us. 2012. 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. 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. Acetic acid irrigant is administered _____ Intravesical. Standardize to a single concentration/bag size for both antepartum and postpartum oxytocin infusions (e.g., 30 units in 500 mL Lactated Ringers). Accessed August 24, 2022. 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. 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. Addressing drugs given by a certain route of administration (e.g., intrathecal, epidural) or in special populations (e.g. ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study. ISMP Med Saf Alert Acute Care. To update the list, practitioners were once again surveyed. As a nurse faces prison for a deadly error, her colleagues worry: could I be next? opioids. pediatrics) as high-alert can be effective as well. https://www.ismp.org/recommendations/high-alert-medications-acute-list, Community/Ambulatory Setting: Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. 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. 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). Policies, HHS Digital Nursing home patient safety culture perceptions among US and immigrant nurses. Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. 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). 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. 2023 Institute for Safe Medication Practices. Get notified when a new bulletin is released. << Annual Perspective: Topics in Medication Safety. C (e.g., chemotherapy, opioid infusions, intravenous [IV] insulin, heparin infusions). Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications. potassium chloride for injection concentrate. 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. However, this is just the first step in safeguarding the use of high-alert medications. Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing. Department of Health & Human Services, Horsham, PA: Institute of Safe Medication Practices; 2021. anticoagulants. Telephone: (301) 427-1364. Electronic 440,000 . All rights reserved. FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters. Annual Perspective: Psychological Safety of Healthcare Staff. To guide this process, please consider the following: Hospitals need a list of targeted high-alert medications that is comprehensive enough to address the most potentially harmful errors while not being so inclusive that the list is overwhelming. Us. Nursing Interventions Classification (NIC) - Gloria M. Bulechek . Strategy, Plain This initiative will help address recommendations from the Gillese Inquiry, including strengthening medication management to deter and detect intentional and unintentional harm in homes. Search All AHRQ Institute for Safe MedicationPractices 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 Policy, U.S. Department of Health & Human Services. Please select your preferred way to submit a case. ISMP List of High-Alert Medications in Community/Ambulatory Healthcare Author: ISMP Subject: High-alert medications Created Date: 20110129135114Z . 5200 Butler Pike /Type/ExtGState 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. Strategies must be sustainable over time. This current list reflects the collective thinking of all who provided input. Medication safety in primary care practice: results from a PPRNet quality improvement intervention. Department of Health & Human Services. Learn more information here. 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. ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. 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