Vol. 24 No. 11 November 2014 Medications Having a High Risk of Causing Serious Injury or Death by Pat Uselton, Director Quality and Pharmacy Practice, Cardinal Health Some medications carry a higher risk of causing death or serious injury to patients than others. Every organization should identify their high-alert medications (e.g., concentrated electrolytes, insulin, anticoagulants, opiates, and chemotherapy agents) and implement processes to reduce the risk of errors. This issue of Quality Matters lists some high-alert medications, their common risk factors, and some suggested strategies for reducing the risks. Organizations should be innovative in their quest for safer medication processes, as well as, using those methods already proven to be effective. Organizations are encouraged to consider the following strategies, as well as others that may be applicable. Medications and Risk Factors Insulin • Wrong dose administered • Storage of multiple types of insulin in a common bin • Confusing insulin vials with heparin vials • Writing or allowing order sets to contain “U” for “units” (which can be interpreted as a zero) • Programming the wrong rate into an infusion pump Opiates and Narcotics • Inappropriate access to controlled substances • Confusing HYDROmorphone and morphine • Programming the wrong concentration and rate in infusion pumps Strategies for Reducing Risks • • • • • • • • Potassium Chloride/Phosphate Concentrate • Storing potassium chloride/phosphate concentrated injections in floor stock • Preparing injectable potassium solutions in patient care areas • Ordering unusual concentrations Intravenous Anticoagulants (Heparin) • Unclear labeling of concentration and total volume • Miscalculation of heparin doses • Writing “U” for “units” which can be interpreted as a zero • Using multiple-dose containers of heparin • • • • • • • Require an independent double-check of doses by another individual Do not co-mingle different types of insulin in a single bin – store in separate bins Store insulin and heparin separately Do not write or allow order sets to contain “U” for units – always spell out “units” Identify a small set of situations that require an independent double-check Minimize diversion by locking all controlled substances and limiting access to authorized personnel Use Tall Man lettering on labels, MARs, and orderentry and ADC screens Identify a small set of situations that require an independent double-check of drugs, concentrations, and rate settings on infusion pumps Store injectable concentrated potassium products only in the pharmacy Use commercially-prepared, pre-mixed potassium products Standardize and limit concentrations Standardize heparin concentrations and use premixed solutions only Do not write “U” for “units” – always spell out “units” Remove all 10,000 per ml heparin vials from floor stock Use only single-dose containers of heparin Medications and Risk Factors Sodium Chloride Solutions Above 0.9% • Storing sodium chloride solutions above 0.9% in areas outside the pharmacy, including Materials Management • Having unneeded and unusual concentrations of sodium chloride available for use (e.g., hypertonic saline in ED) • Failing to double-check drugs and concentrations Chemotherapy Agents • Unclear orders; use of acronyms in orders • Miscalculation of dosing regimens • Miscalculation of intravenous pump settings • Dosing vinca alkaloids in syringes Strategies for Reducing Risks • • • • • • • Neuromuscular Blocking Agents • Mistaken for another drug on patient care areas • Staff are not competent to use this type of medication • Inadvertently used in patients without proper ventilator assistance Look-alike and Sound-alike (LASA) Drugs • Drugs with similar sounding names are often confused • Drugs with similar looking names are often confused • • • • • • • • • • • Remove sodium chloride solutions above 0.9% from all locations other than the pharmacy Limit the number of sodium chloride concentrations available for use and stock only in the pharmacy Require an independent double-check of drugs and concentrations Use approved, standardized, preprinted order forms for all chemotherapy agents Require patient height and weight to calculate body surface area for all chemotherapy orders Require an independent double-check of all dose calculations and settings for infusion pumps prior to administration Place doses of vinca alkaloids in piggyback dosage forms Distinctively label as a high-alert drug Limit storage to the pharmacy, OR, ED, and critical care units, require a prospective risk assessment such as failure mode and effects analysis (FMEA) for exceptions Limit access to staff with documented competence Identify a list of pairs (no more then 10) of LASA drugs on which to concentrate Use distinctive lettering (e.g., TALLman lettering) Require physical separation in all storage areas Do not store in matrix drawers in ADCs Use different color storage bins in the pharmacy and on patient care areas Use distinctive, brightly-colored labels for high-alert or LASA drugs Require indication for use on all medication orders Spell out names when giving or reading back verbal orders – TEST – 1. T F Potassium chloride/phosphate concentrated injections should not be available in patient care areas. 2. T F Confusing insulin vials with heparin vials often leads to serious medication errors. 3. T F Minimizing access to injectable narcotics in floor stock is a risk reduction strategy. 4. T F The word “units” should never be spelled out – always use the abbreviation “U”. 5. T F Hypertonic saline can be stored in the ED since it may be needed frequently. Prepared by Cardinal Health Nothing in this publication shall be construed as authorizing or permitting any person to do any act that is not authorized or permitted under Federal or State laws. Some State laws may be more stringent than Federal laws. © 2014 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.