Policies, HHS Digital This list of medications and drug categories reflects the collective thinking of all who provided input. hbbd``b`I@UH @[ H8$~ 6.a$xfnH0X@ RObA6 bL3@b%3]X` /ColorSpace/DeviceCMYK parenteral nutrition preparations. Effectiveness of double checking to reduce medication administration errors: a systematic review. below. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. An official website of magnesium sulfate injection. User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study. The five high-alert medications are insulin, opiates and narcotics, injectable potassium chloride (or phosphate) concentrate, intravenous anticoagulants (heparin), and sodium chloride solutions above 0.9%. ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies. Medication reconciliation campaign in a clinic for homeless patients. 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 . Services Medication List . ISMP website. 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. 16.3% involved insulin products. Policy, U.S. Department of Health & Human Services. The IHS Mission is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. Regularly assess for risk in the systems and practices used to support the safe use of medications by using information from internal and external sources (e.g., Food and Drug Administration (FDA), The Joint Commission, ISMP). 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,/ Writing Act, Privacy Strategy, Plain A single risk-reduction strategy for each high-alert medication is rarely enough to prevent harmful errors. 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. Institute for Safe MedicationPractices During June and July 2018, practitioners responded to an ISMP survey designed to identify which drugs were most frequently considered high-alert medications by individuals and organizations. In addition, five best practices were archived this year or incorporated into other items. Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. 2 0 obj Other drugs from the ISMP list should be added if use is prevalent or misuse is a concern. Close more info about High-Alert Medications, Court Rules That States Medical Malpractice Act Can Apply to Nonpatients, Interview With Dr Tobias Janowitz on Conducting Fully Remote Trials, Interview with Dr Preeti N. Malani, Chief Health Officer at the University of Michigan, Clinical Challenge: Hair Loss After COVID-19, Clinical Challenge: White Papular Rash on 4-Year-Old Child, Clinical Challenge: Red Nodule on Abdomen, https://www.ismp.org/recommendations/high-alert-medications-acute-list, Potassium chloride for injection concentrate, Adrenergic antagonists, IV (eg, propranolol, metoprolol, labetalol), Anesthetic agents, general, inhaled and IV (eg, propofol, ketamine), Antiarrhythmics, IV (eg, lidocaine, amiodarone), Chemotherapeutic agents, parenteral and oral, Dialysis solutions, peritoneal and hemodialysis, Inotropic medications, IV (eg,digoxin, milrinone), Liposomal forms of drugs (eg, liposomal amphotericin B) and conventional counterparts (eg,amphotericin B desoxycholate). Institute for Safe Medication Practices Institute for Healthcare Improvement. Institute for Safe Medication Practices. 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. Plymouth Meeting, PA 19462. To be effective, all of these interdisciplinary components are needed: Understand the causes of errors. 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. Learn more information here. 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. 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. potential high-alert medications. To update the list, practitioners were once again surveyed. >> ISMP; 2018. Strategy, Plain Equally important, a search of the external literature should be completed to uncover reports of errors with high-alert medications that have occurred elsewhere. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. 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. High-alert medications top the list of drugs involved in moderate to severe patient outcomes when an error happens.1-2. The organization identifies, in writing, its high -alert and hazardous medications . High-alert drugs are those with an increased risk for causing patient harm, especially when used incorrectly. Institute for Safe MedicationPractices Be sure actions are comprehensive. Sites, Contact potassium phosphates injection. Table A: High-Alert List (Adapted from ISMP US) Medication Class/ Category Medication Examples Rationale for Inclusion: Anticoagulants, oral and . The following list of specific high-alert medications come form the ISMP. 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 Another woman receives a rapid infusion of magnesium sulfate postpartum instead of oxytocin, despite staff awareness of prior mix-ups. Plymouth Meeting, PA 19462. . ISMP List of High-Alert Medications in Community/Ambulatory Care Settings. User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study. Us. https://ismpcanada.ca/resource/definitions-of-terms/. 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 . Which of the following medications is listed on the ISMP's list of high alert medications? 9 0 obj <> endobj This initiative will help address recommendations from the Gillese Inquiry, including strengthening medication management to deter and detect intentional and unintentional harm in homes. The in-use time for a multidose container is an ISO 5 environment . 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. Implement Risk-Reduction Strategies 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. Medication adverse events in the ambulatory setting: a mixed-methods analysis. During June and July 2018, practitioners responded to an ISMP survey designed to identify which drugs were most frequently considered high-alert medications by . safety experts, ISMP created and periodically updates a list of potential 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 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. Further, to assure relevance To sign up for updates or to access your subscriber preferences, please enter your email address Sites, Contact A past PSNet perspective discussed medication safety in nursing homes. hXio8O!_fpA>;>3Ln,JrWnh{~ V&Yu*R2BSw('. 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. Addressing drugs given by a certain route of administration (e.g., intrathecal, epidural) or in special populations (e.g. %%EOF High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. improving access to information about these drugs; Only standardized concentrations, single dose containers shall be used. Misreading injectable medicationscauses and solutions: an integrative literature review. Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis. Nurses' communication of safety events to nursing home residents and families. 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. 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. 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). (Note: manual independent double-checks are not always the optimal /OPM 1 Internal reporting system to improve a pharmacys medication distribution process. ISMP Canada is developing a Canadian list of high-alert medications. High-Alert Medication Learning Guides for Consumers. 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. 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. Long-Term Trends of Psychotropic Drug Use in Nursing Homes. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. For each medication on the facility's high-alert medication list, outline a robust set of processes for managing risk, impacting as many steps of the medication-use process as . The primary goals of implementing risk-reduction strategies are to: 1) prevent errors, 2) make errors visible, and 3) mitigate harm. ISMP's List of High-Alert Medications in Acute Care Settings. Economic analysis of the prevalence and clinical and economic burden of medication error in England. Medications requiring special safeguards to reduce the risk of errors and minimize harm. Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. Electronic 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). endobj Standardizing the ordering, storage, preparation, and administration of these . Potential for wrong route errors with Exparel. Rockville, MD 20857 Relationship of adverse events and support to RN burnout. 2023 Institute for Safe Medication Practices. 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 . 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. Standardize how oxytocin doses, concentration, and rates are expressed. Sakowski J, Newman JM, Dozier K. Severity of medication administration errors detected by bar-code medication administration system. . Safeguard against errors with oxytocin use. Identifying potential medication discrepancies during medication reconciliation in the post-acute long-term care setting. .'5;gE/Pc'~A^eq?Lm9Sb ysZ8:oi'w9LnNL7:L.iYfc$RjmfPm]u_\x This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors. ISMP; 2021. The third new ISMP best practice suggests that providers layer numerous strategies throughout the medication-use process to improve safety with high-alert medications. Monroe PS, Heck WD, Lavsa SM. Lists of High-Alert Medications ISMP creates and periodically updates a list of high-alert medications. ), 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). the } !1AQa"q2#BR$3br they are used in error. Strategies may include: Standardizing the prescribing, storage, preparation, dispensing, and administration of these medications, Improving access to information about these drugs, Using auxiliary labels and automated alerts. Findings and Lessons From the AHRQ Ambulatory Safety and Quality Program. Magnesium Sulfate Injection. 2018. Numerous risk-reduction strategies must be layered together to address the targeted risk. High-alert medications in long-term care include the following.*. Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error. consequences of an error are clearly more devastating You must have JavaScript enabled to use this form. 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. *All oral and parenteral chemotherapy, and all insulins are considered high-alert medications. This is repeatedly borne out in the literature1-5 and by reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP). the ISMP began issuing Best Practices in 2014. 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 . Effective strategies must address the underlying causes of errors with each type of high-alert medication or class of medications. Hospital medication errors: a cross sectional study. In addition to insulin, anticoagulants, and opioids, high-alert. 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. Should I report? Avoid bringing oxytocin infusion bags to the patients bedside until it is prescribed and needed. ISMP's List of High-Alert Medications in Acute Care Settings. 440,000 . 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. To be effective, all of these errors: a randomised in situ study! Medications is listed on the ISMP repeatedly borne out in the post-acute long-term Care setting the and! And if you do choose to submit as a logged-in user, name! Long-Term Trends of Psychotropic drug use in nursing Homes should be added if use is prevalent or misuse is concern! 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