Improve the Safety of High-alert
1.1. Labeling:
1.1.1. To draw attention about the high alert medication risk of harm from error that can
occur with these medications during preparation, dispensing, and administration, labels
for these medications will include the comment: “HIGH ALERT – Use Caution”.
Auxiliary labels are attached to characterize specific medication categories as follows :
1.1.1.1. High concentrated electrolytes will be labeled red with High alert medication
red label tagged on each ampoule during preparation by the qualified nurse
and checked by the nursing staff.
1.1.1.2. Look alike/sound alike medications will be labeled with High alert yellow
label
1.1.1.3. The other high alert medications will be labeled with orange label.
1.1.2. Labels of high alert medication should be easily accessible for providers licensed to
dispense or administer medications in the medication storage areas.
1.1.3. The updated list of high alert medication including look-alike/sound-alike
medications should be:
1.1.3.1. Available in each department dealing with high alert medication.
1.1.4. Easily accessible as a reference for providers licensed to order, dispense or administrator
high alert medication.
1.1.5. The high alert medication shall be updated annually.
1.2. Dispensing:
1.2.1. The dose will be labeled with the high alert medication label; the medication will be
labeled with the patient name and medical record number, the name of the drug, its
concentration, rout, and any specific precautions for administration.
1.2.2. When the vial/ampoule is not completely used the remaining must be discarded and a
new vial will be issued by the pharmacy with the next due dose.
1.2.3. Providers licensed to order, dispense or administrator of high alert medications have to
be properly oriented to the availability and use of high alert medications.
1.3. Administration:
1.3.1. Double check of high alert medication:
Page 1 of 2
GMMC-MED-P&P-003
Version No.: 1
Issue Date: 01/12/2017
Next Reversion Date: 30/11/2020
Improve the Safety of High-alert
1.3.1.1. The dispensing pharmacist and the receiving nurse should check the five rights
of high alert medication separately (alone and apart from each other) by
comparing the medication documented in medication sheet and dispensed and
verifying the high-alert medication before administering it to the patient.
1.3.1.2. Double check should be documented in the medication sheet with the names
and signatures of the persons who implemented the double check.
1.3.1.3. The minimum requirement for the medication double check will occur with
each dose/injection for infusions:
1.3.1.3.1. At the time of initiation of therapy.
1.3.1.3.2. At the time of concentration changes.
1.3.1.3.3. With any dose change.
1.3.1.3.4. With any bottle/ bag change.
1.4. Discarding and disposing of high alert medication:
1.4.1. High Alert Medications should be disposed safely according to each medication’s
way of safe disposal.
1.4.2. More detailed policies exist for some of these drugs/drug classes, and these policies
are also referenced below.
1.5. Patient education:
1.5.1. When delivering the patient his medication, the pharmacist in charge of patient
education should make sure that the patient knows all the important precautions
concerning his medication.
2. References:
2.1. Joint Commission International Accreditation Standards for Hospitals, 6th edition.
2.2. Institute for Safe Medication Practiceshttp://www.ismp.org/faq.asp
3. Related Form(s):
3.1. Medication order Sheet
3.2. Narcotic Drug Register
GMMC-PHR-FRM-002
GMMC-PHR-FRM-019
4. Related Policy and Procedure(s):
4.1. Medication dispensing policy
GMMC- PHR-P&P-007
5. Attachment(s)
5.1. List of High Alert medications.
5.2. List of Look-alike medications.
5.3. List of Sound-alike medications.
5.4. List of strategy to minimize risk of medications errors
Page 2 of 2
GMMC-MED-P&P-003
Version No.: 1
Issue Date: 01/12/2017
Next Reversion Date: 30/11/2020