Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 1, No. 3 (September 2004) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Focus on High-Alert Medications W hile all medications have a level of risk if used incorrectly, a small number of medications bear a heightened risk of significant patient harm • but received 50 mLs. Insulin was administered to the wrong patient when they are used in error. These drugs are com- based on blood sugar levels of another patient. monly referred to as “high-alert” medications. • Two reports concerned patients receiving con- Though mistakes may or may not be more common centrated epinephrine 1:1,000 undiluted intrave- with these drugs, the consequences of errors with nously. these medications are more devastating to patients. A 1998 Institute for • An intravenous heparin infusion was pro- Approximately one in Safe Medication Prac- grammed to run at 150 mL/hr (the rate for the four medication error tices (ISMP) study re- patient’s antibiotic) rather than the ordered rate of 10 mL/hr. reports submitted to vealed that 11% of all PA-PSRS involves a serious medication A list of common high-alert medications is available errors involve insulin as a drop down box when entering reports into PA- high-alert medication. misadministration, and PSRS at question 23. In addition, a complete list is another 8.9% involved available from ISMP (www.ismp.org/MSAarticles/ heparin.1 In addition, the summary information from highalert.htm) as well as in the PA-PSRS Training the MedMarxSM 2002 report found that the top seven Manual and Users’ Guide in Appendix B, page 87. medications involved in events involving harm (comparable to Harm Score Categories E thru I in Additionally, the Joint Commission on Accreditation PA-PSRS) are high-alert medications including insu- of Healthcare Organizations (JCAHO) includes in lin, morphine, heparin, intravenous concentrated their 2004 National Patient Safety Goals that or- potassium chloride, warfarin, hydromorphone, and ganizations “improve the safety of using high-alert fentanyl.2 These medications along with meperidine, medications” by removing concentrated electrolytes intravenous chemotherapy, and neuromuscular (including, but not limited to, potassium chloride, blocking agents are among those considered high- alert medications. potassium phosphate, and sodium chloride >0.9%) from patient care units and standardizing and limit- Among medication error reports submitted to PA- ing the number of drug concentrations available in PSRS, approximately one out of four reports involve the organization.3 high-alert medications. Of those reports: Strategies to safeguard the medication use process • 44% involved pain management medications for high-alert medications may include limiting ac- including morphine, hydromorphone cess to these medications; using auxiliary labels (DILAUDID®), meperidine (DEMEROL®) and and automated alerts; standardizing the ordering, fentanyl. preparation, and administration of these products; and employing automated or independent double • 14.2% involved heparin. checks when necessary. • 16.3% involved insulin products. This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 1, No. 3—September 2004. The Advisory is a publication of the Pennsylvania Patient • 9.4% involved warfarin (COUMADIN®). Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Sixty-five percent of Serious Events involving medi- cations involved high-alert medications. Examples Copyright 2004 by the Patient Safety Authority. This publication may be re- of medication errors involving high alert medications printed and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their include: entirety and without alteration provided the source is clearly attributed. • A patient receiving an infusion of fentanyl for To see other articles or issues of the Advisory, visit our web site at pain control was ordered a 50 mcg bolus dose, www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2004 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 1, No. 3 (September 2004) Focus on High Alert Medications (Continued) Notes 1. Cohen MR, et al. Survey of hospital systems and common serious medication errors. J Healthc Risk Manag 1998;8(1):16- 27. 2. Hicks RW, Cousins DD, Williams RL. Summary of information submitted to MEDMARXsm in the year 2002: The quest for qual- ity. Rockville (MD): USP Center for the Advancement of Patient Safety; 2003. 3. Joint Commission on Accreditation of Healthcare Organiza- tions. Facts about the 2004 national patient safety goals [online]. 2003 Jul 18. Available from Internet: http://www.jcaho.org/ accredited+organizations/patient+safety/04+npsg/facts+about +the+04+npsg.htm Page 2 ©2004 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 1, No. 3 (September 2004) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. ©2004 Pennsylvania Patient Safety Authority Page 3