High Alert Medication

High Alert Medication

1. Presented by: Dr.Amira Al Raidan Director for Health education & awareness programs Head of mental health department Sultanate Of Oman Ministry Of Health Primary Health Care

2. The scope of this presentation,,, Discuss the concept of high-alert medications. Identify the many drug classes considered to be high-alert status. Demonstrated case-scenarios. Describe various strategies for safeguarding (monitoring), the use of high-alert medications.

3. High-alert medications: Are drugs that bear a heightened risk of causing significant patient harm when used in error. Errors may not be more common with these than with other medications, but the consequences of errors may be devastating.

4. Adrenergic agents Anesthetics Antiarrhythmics Anticoagulants Cardioplegic solutions Chemotherapy Dextrose ≥20% Dialysis solutions Electrolytes (concentrated) Epidural/ intrathecal agents Epoprostenol Inotropic agents Insulin/ hypoglycemics Liposomal products Narcotics Neuromuscular blocking agents Nitroprusside Oxytocin Parenteral nutrition Promethazine Radiocontrast agents Sedatives Sterile water for injection www.ismp.org/Tools/highalertmedications.pdf ISMP’s List of High-Alert Medications

5. 1- Insulin. 2- Opiate and Narcotics. 3- Injectable Potassium chloride or phosphate. 4- Injectable Anticoagulant. 5- Sodium chloride solution above 0.9%. The top five high-alert medications

6. 2- Opiates and Narcotics Factors contributing to harm : • Calculation errors. • IV to PO conversion errors. • Errors converting potency when changing from one narcotic to another. • Many dosage forms.

7. - Parenteral narcotics stored in nursing areas as floor stock. - Confusion between hydromorphone and morphine. - Patient-controlled analgesia (PCA) errors regarding concentration and rate. Adverse effets : - Respiratory depression - Confusion - Lethargy Cont..

8. Case s cenario-1 A 27 years old Omani gentleman, married with two kids, working as heavy driver at private sector. F requently visiting different health centers with similar complaint of multiple j oint pain, generalized w eakness , blurred vision and p oor sleep + appetite. Each time he comes to A&E, he is screaming he is in pain & rolling on the floor.

9. Case s cenario-2 A 33 years old Omani gentleman, single, studying at college. Brought unconscious, forearm multiple cut w ounds. Unstable vitals. As attendant stated patient was unsell … looks in pain but refuse to talk….stay at his room. 3 days back patient behaved strangely as being aggressive, paranoid, awake all the night & refuse to eat.

10. Understanding pain An unpleasant sensory and emotional experience... ...caused by actual or potential tissue injury, ...or described in terms of such injury.

11. To improve:- Comfort. Function. Safety. Prevention of expected side effects of opioids use. Goals of pain management

12. General assessment Management / Intervention Reassessment Principles of pain management

13. Cause of pain. The location of pain. The characteristic of pain. The severity and intensity of pain. Duration of pain. The impact of quality of life. Medication-current and previous analgesics. A ny relieving factors. Considerations in pain treatment

14. Healthcare Professionals Barriers: Fail to routinely assess and document pain. Lack of knowledge and skills. Lack of effective treatment protocols. Fears from side effects of opioids & addiction Barriers to Effective Pain Management

15. Pain Rating Scale Step I: Mild pain. Non-opioid e.g. paracetamol or NSAID s Step II: Moderate pain. Mild-opioid e.g.codeine +/- non-opioid +/- adjuvant Step III: Severe pain. Strong opioid (e.g. morphine) +/- non-opioid +/- adjuvant

16. Step I: Mild pain. Non- opioid such as paracetamol or NSAIDs Step II: Moderate pain. Mild- opioid ( e.g.codeine ) +/- non- opioid +/- adjuvant Step III: Severe pain. Strong opioid (e.g. morphine) +/- non- opioid +/- adjuvant The WHO Analgesic Ladder

17. Tramadol Mechanism of action: Centrally acting analgesic Dual action by binding to the opioid receptor site (CNS) By weakly inhibiting the reuptake of biogenic amines A weak opiate receptor agonist. Hence, does not produce significant respiratory depression. Availability: Capsules 50mg Injection 100mg/ 2ml Oral drops 100mg/1ml= 2.5mg/drop Analgesics for Moderate pain

18. A chemical that works by binding to opioid receptors , which are found principally in the central and peripheral nervous system and the gastrointestinal tract. Examples of Opioid analgesics : Codeine Morphine Pethidine . F entanyl Opioid analgesics

19. Opioid analgesics

20. Nausea & Vomiting Tolerance to this side effect occurs over time. Constipation All patients on around-the-clock opioids should also receive a stool softener and mild stimulant laxative. Tolerance to constipation does not occur over time. Preventing & Managing Common Opioid Side Effects

21. 3 . Pruritus May be treated with antihistamine ( e.g.chlorphinramine ). Tolerance occurs over time. 4. Sedation & Respiratory Depression Consider giving a lower opioid dose more frequently to decrease peak serum concentrations. Tolerance to this side effect occurs over time. Naloxone (toxicity management) Preventing & Managing Common Opioid Side Effects

22. Antidote – naloxone MOA: Pure opioid antagonist competes & displaces narcotics at opioid receptor sites I.V. (preferred), I.M., intratracheal , SubQ : 0.4-2 mg every 2-3 minutes as needed Lower doses in opiate dependence Elimination half-life of naloxone is only 60 to 90 minutes Repeated administration/infusion may be necessary S/E: BP changes; arrhythmias; seizures; withdrawal Opiates

23. Antidote – flumazenil MOA: Benzodiazepine antagonist IV administration 0.2 mg over 15 sec to max 3mg S/E: N&V; arrhythmias; convulsions C/I: Status epilepticus Should not be used for making the diagnosis Benzodiazepines may be masking/protecting against other drug effects Benzodiazepines

24. ABC Vital signs, mental status, and pupil size Pulse oximetry , cardiac monitoring, ECG Protect airway Intravenous access Cervical immobilization if suspect trauma Rule out hypoglycaemia Role out opiates abuse…..> do Urine Drug Screening (if available). Naloxone for suspected opiate poisoning Supportive care

25. Pain as a disease Pain Depression Think negative In-activity Medical Dependence Insomnia Socially deprived

26. Under-managed chronic pain may lead to: Less sleep (insomnia) Exhaustion (diminished quality of life) More stress Social relationship and work problems (Absenteeism, unemployment, and under-employment) Psychological distress (depression, anxiety) Chronic pain and its psychological effects have the potential to reduce quality of life, not only for the person with pain but for the family as well.

27. So ,,, it is important to be able to intervene in this cycle to improve pain management and psychological welfare.

28. Managing the emotions can directly affect the intensity of pain.

29. Framework for Safeguarding High-Alert Medication Use

30. Reduce or eliminate the possibility of errors. Make errors visible. Minimize the consequences of errors. Primary Principles

31. Simplify: Reduce steps and number of options. Externalize or centralize error-prone processes, i.e : I.V preparations…. For example: Use commercially prepared premixed products - Premixed magnesium sulfate, heparin, etc. Centralize preparation of IV solutions - Prepare pediatric IV medications in pharmacy Differentiate items: Appearance , location Touch, color, smell, etc. Key Concepts in Safeguarding High-Alert Medications

32. Standardize: Communication and dosing methods. Redundancy ( System of independent checks ) : Is the Probability that two individuals will make the same error is small; therefore, having one person check the work of another is essential. Check systems, back-ups ( Match high-alert drug orders to the patient’s diagnosis, the drug’s indication, and vital patient information ) For example: Calculations for pediatric patients, select high-alert medications, etc., performed independently by at least two individuals, with identical conclusions. Key Concepts in Safeguarding High-Alert Medications (continued)

33. Reminders. Improve access to information ( i.e computerized drug information resources (handheld ). Constraints that limit access or use in risky situations ( Reduce access to dangerous items by careful selection of medications and quantities in storage). Protocols, checklists, visual and audible alarms. Patient monitoring. Key Concepts in Safeguarding High-Alert Medications (continued)

34. Summary,,,

35. Develop policies regarding the use of high-alert drugs. Assess and implement storage requirements of high-alert drugs. Develop and institute standardized order sets. Ensure the process of evaluating potential formulary additions identifies high-alert medications. Implement a Safety Checklist for High-Alert Drugs

36. A. Closely monitoring the patient’s - level of consciousness - vital signs - respiratory status - lab results B. Ensuring that reversal agents and resuscitation equipment are readily available. C. Include patient monitoring parameters in all protocols and order sets. Key Concepts in Safeguarding High-Alert Medications (continued)

37. Institute for Safe Medication Practices. ISMP’s list of high-alert medications. ISMP Medication Safety Alert! March 27, 2008;13(6). Institute for Safe Medication Practices. Survey on high-alert medications. Differences between nursing and pharmacy perspectives revealed. ISMP Medication Safety Alert! October 16, 2003;8(21 ). http://www.ismp.org/newsletters/acutecare/articles/20070517.asp References