Medications Having a High Risk of Causing Serious Injury or Death

Vol. 24 No. 11
November 2014
Medications Having a High Risk of Causing Serious Injury or Death
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
• 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
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
• 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
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
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
• Staff are not competent to use this type of
• Inadvertently used in patients without proper
ventilator assistance
Look-alike and Sound-alike (LASA) Drugs
• Drugs with similar sounding names are often
• Drugs with similar looking names are often
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
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
Place doses of vinca alkaloids in piggyback dosage
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
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
– 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.