Reduction of harm from high risk medications

High risk medications are medicines that are most likely to cause significant harm to the patient, even when used as intended. The Institute for Safe Medication Practices (ISMP) reports that the incident rates of this group of medicines may not necessarily be higher than the other medicines but when incidents occur the impact on the patients would be serious (significant).

In seeking to improve patient safety, the primary focus should be on preventing errors with the greatest potential for harm. Many of the highest risk medications - e.g., heparin, insulin, morphine, and propofol e are delivered by IV infusion. 61% of the most serious and life threatening potential adverse drug events (ADEs) are IV drug related.
IV administration often results in the most serious outcomes of medication errors.

1.  
 
 
 
 
                  
 
                  
                       
                       
R
                                    
Reduction
      
of harm ffrom high
  
risk mediications

2. Reduction of harm from high risk medications
Gaurav Loria
a
ABSTRACT
High risk medications:High risk medications are medicines that are most likely to cause significant harm to the
patient, even when used as intended. The Institute for Safe Medication Practices (ISMP) reports that the incident
rates of this group of medicines may not necessarily be higher than the other medicines but when incidents occur the
impact on the patients would be serious (significant).
In seeking to improve patient safety, the primary focus should be on preventing errors with the greatest potential for
harm. Many of the highest risk medicationsee.g., heparin, insulin, morphine, and propofoleare delivered by IV
infusion. 61% of the most serious and life threatening potential adverse drug events (ADEs) are IV drug related.
IV administration often results in the most serious outcomes of medication errors.
Copyright©2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords:High risk medication, ISMP, High alert medications
INTRODUCTION
ISMP defines High Alert Medications as,“drugs that bear
a heightened risk of causing significant patient harm when
they are used wrongly. Although mistakes may or may not
be more common with these drugs, the consequences of an
error are clearly more devastating to patients.”
HIGH RISK MEDICATIONS: (ACCEPTED
WORLDWIDE)
1)Concentrated electrolytes:>0.9% sodium chloride,
magnesium sulphate, and potassium chloride
2)Anticoagulants: heparin
3)Human insulin:human actrapid, human insulatard
and other insulins (all short, long and intermediate
acting)
4)Narcotics: morphine, fentanyl, pethidine
5)Chemotherapeutic agents
6)Look alike and sound alike drugs (LASA)
The risks caused due to the high risk medications are
given in the table below
Coordinator QualityeApollo Group, Consultant QualityeApollo Clinics, 108 Nehal Chambers, Apollo Hospitals, Jubilee Hills, Hyderabad, India.
a
The project was done at the time when we had only concentrated electrolytes as our high alert medications. This project was done and after the
results we added other drugs (high risk) in our list as well.
Received: 30.4.2012; Accepted: 1.5.2012; Available online: 8.5.2012
Copyrightfi2012, Indraprastha Medical Corporation Ltd. All rights reserved.
doi:10.1016/j.apme.2012.05.001
Apollo Medicine 2012 June
Volume 9, Number 2; pp. 160e165
Article on Quality

3. OBJECTIVES OF THE STUDY
dTo know the current status of the care in the delivery of
high risk medications to the patients
dTo intervene if any care in the delivery of the high risk
medications is still required
METHODOLOGY OF STUDY
dA random study was conducted in the hospital in all
ICUs, 1st and 2ndfloors.
dThe study had been carried out for6 weeks.
dOver 100 patients were studied with regard to the care in
administrationof high risk medications.
dOver 100 samples were studied with regard to the
dispensingof the high risk medications to the patients
from the pharmacy and storage in the pharmacy.
INCLUSIONS OF THE STUDY
dAll the patients in the ICUs, 1st and 2ndfloors were
included in the study.
dThe casefiles of all the patients were referred for the
required information.
dThese patients were observed for the proper administration of
the high risk medications in the respective departments.
dThe dispensing of the high risk medicines was observed
during morning and the evening time.
EXCLUSIONS OF THE STUDY
dLASA drugs were excluded.
dDispensing during the night time was excluded.
dChemo drugs were excluded for the three quarters of the
study.
INTERPRETATIONS
Theerrorsobserved in the administration and transcrip-
tions were
dDrugs indented but not administered
dDrugs not written in the high alert chart by the physicians
dNo double signatures in the drug chart after adminis-
tering the narcotics
dHypoglycaemia not monitored and documented.
dMagnesium levels were not monitored after the adminis-
tration of the electrolyte magnesium sulphate
dBlood pressure, when improper after the administration
of fentanyl not corrected
dIndications for the drugs not written in the drug chart
especially in case of chemo drugs
dCorrect date is not written in the drug chart
dWrong drugs are written in the high alert chart
dStop orders not written in the high alert chart
DETAILED DESCRIPTION OF THE INTERPRE-
TATIONS OF THE STUDY
dAmong 110 patients observed for the administration of
the high risk medications,50errors were found to occur
i.e., at the rate of45.5%(Fig. 1)
Medicine group Risks to the patient
Anticoagulants Narrow therapeutic index,
potential for clot or bleed,
interactions with other
medications even herbal
medicines, over the counter
drugs and food
Opiates Sedation, respiratory depression,
confusion, lethargy, nausea,
vomiting, constipation
Insulin Loss of blood sugar control in
post-operative patients, achieving
blood sugar control without
causing hypoglycaemia
Concentrated
electrolytes
Increase in the level of the
electrolytes leading to lethal effects
LASA Risk of administration of the
incorrect medications and the
consequent adverse effects
GraphAnalyzed results- errors in high risk medication
administration.
Reduction of harm from high risk medications Article on Quality 161

4. dAmong all the errorswhich were observed
B20%of the errors happened to be theabsence of
double signatureduring the administration of the
high risk medications mostly concentrated
electrolytes
B10%of the errorsehigh risk medicationsnot written
in high alert chartof the drug chart by the physician
dAmong the errors observed theareas of errors
BAbsence of double signatured70% of was observed
in CT post
BThe other areas were the errors were observeddPICU,
regency IIIfloor, IIfloor, cancer block
dThereasonsfor the errors found are
BLack of proper training to the staff with regard to the
specific drugs
BLack of time
BIgnorance of the staff with respect to continuous
implementation of the policy guidelines
BLack of monitoring by the accountable authority
dTheinterventionsought to be carried out tominimise
the errorswere
First and foremost is theproper trainingof the staff
in terms of the policy which includes the list of the high risk medicines and all its required guidelines
Monitoringthe staff for the follow up of the policy
Putting up display chartsdepicting the policy of
administration of the high risk medications so that the staff will be reminded of the policy
Make thesenior staff accountablefor the regular
implementation of the policy
Set up a deadline (time period) for the review of the
performance of the staff after the intervention
Review the performance of the hospital staff after
the intervention for the knowledge of the improve-
ment in the policy implementation
Rewardthe department or the staff who succeed in
following the policy and responsible for the change in
the implementation of the policy
Motivatethe staff with regard to the policy
implementation
Periodical review(monthly) of the follow up of the
policy by the medication safety committee
MEDICATION
ERROR
MAN MACHINE
METHOD ENVIRONMENT
Floor wise dispensing
counters not available
Wrong selection of drugs
Wrong verbal order taken
by staff
Staff not complying with two identifier
while labeling and administering drugs
Pharmacy staff not trained in drug selection
and packaging
Ward pharmacist not trained to check
prescriptions
Staff not motivated to report errors
Complicated indenting system,
time consuming
No training for
prescription
writing
Nurse not trained to
take verbal orders
INVENTORY
Out of stock
Delay in bringing
medicines from stores
INTERPRETATION
Wrong interpretation of medicine
Illegible
Manual work
Look alike/ sound alike drugs
Incorrect prescription
written by doctor
Junior doctors reluctant to take verbal order
Staff not following 7R check before
administration
Procedure for drug selection and
packaging not in place
Unorganized drug in IP pharmacy
Verbal order taken
Improper procedure for medicine administration
Inappropriate organization
of drugs in IP pharmacy
Unorganized Imprest stock in ward
Noising factors in IP pharmacy
Time for 7R check not
available
Computer system fails to operate
Fig. 1Fish bone analysis - medication errors.
162Apollo Medicine 2012 June; Vol. 9, No. 2 Loria

5. Make antidotes or rescue drugs available at the point
of care for immediate administration and establishing
protocols that allow for nurses to administer antidotes
or reversal agents per protocol without having to
contact a physician.
DISPENSING AND STORAGE OF THE HIGH
RISK MEDICATIONS
dThe high risk medications must be stored in the hospital
pharmacy with special care
ElectrolytesThe concentrated electrolytes (sodium chloride, potas-
sium chloride, magnesium sulphate) must be stored only in the pharmacy. They must not be in the patient care areas
The concentrated electrolytes must be diluted under the
laminar hood of the pharmacy only by the person responsible for dilution
While dispensing they must be sent with the HIGH
RISK MEDICATION sticker
Narcotics
Narcotic drugs (morphine, fentanyl, pethidine) must be
stored under the double lock chamber in the pharmacy. The two keys must be with two separate persons among the pharmacy staff/ nurses (in patient care areas)
After the reception of the indent by the pharmacy, the
indent must undergo double check by the pharmacy staff and the staff responsible must unlock and take out the drug andfill the details in the narcotic drug receipt
The drug must be sent with HIGH RISK MEDICA-
TION sticker
All the narcotics issued by the pharmacy will be docu-
mented in the NARCOTICS BOOK by the concerned pharmacist
Insulin
All the insulin injections must be stored in a separate
refrigerator in the pharmacy
The insulin drugs must be sent with the HIGH RISK
MEDICATION sticker along with the ice pack
Heparin
Heparin must be stored in the lock and key
Heparin must be sent with HIGH RISK MEDICA-
TION sticker
Chemotherapeutic drugs
These drugs are stored in the refrigerator in the phar-
macy (usually chemo unit pharmacy)
They are sent with HIGH RISK MEDICATION sticker
The pharmacist who dispenses the drug takes the signa-
ture of the user department staff who received the drug as it is costly and must not be misused
ERRORS IN DISPENSING
The errors encountered in dispensing of the high risk medi- cations were
dDrugs sent without HIGH RISK MEDICATION sticker
dThe concentrated electrolytes after dilution were handed over directly to the nurse and confusion observed in the dispensing staff whether the medicine has been dispensed
dThe staffs which assemble the indented medicines and send them to the concerned staff for verification forgets
to attach the HIGH RISK MEDICATION sticker and have to be alerted by the verification staff. The chance
of medicine been dispensed without the HIGH RISK
MEDICATION sticker increases the chance of errors.
INTERPRETATION OF THE ERRORS IN
DISPENSING HIGH RISK MEDICATION
dOut of the100 observationsof dispensing of high risk
medication,10% of errorswere observed
dThe dispensing process was taking place quite according
to the policy guidelines
dOut of all the errors,50%were the error ofsending the
medication without HIGH RISK MEDICATION sticker
Reduction of harm from high risk medications Article on Quality 163

6. dMost of the errors were bound to be occurring at the
level of the staff which is assembling the medications
and sending for the verification
REASONS FOR THE ERRORS DURING
DISPENSING
Pharmacy was overcrowded with staff during the peak
time of morning (11 ame2 pm)
Chaos between the staff assembling, verifying, packing
and dispensing the medicines (leads to confusion among
the staff)
Staff unable to handle all the indents which resulted in
delay in dispensing and piling up of the indents
Slow connectivity of the intranet in the hospital due to
which there was a delay in the reception of the indent
INTERVENTIONS FOR PROPER IMPLE-
MENTATION OF THE POLICY GUIDELINES IN
DISPENSING THE HIGH RISK MEDICATIONS
UPharmacy staff to beeducated about the listof the
high risk medications
UDisplay chartsmade available for the policy guidelines
at
dAssembling countersestaff can identify the high
risk drugs and take steps to prevent the error of mixing
them with other drugs while replacing and error of not
placing the high risk sticker
dVerifying countersestaff can easily identify the medi-
cines if they are without sticker, identify the correct
medicine (in case of LASA), easy to alert the dispensing
staff not to mix with other drugs
dPacking and dispensing countersestaff can easily
separate them and dispense them mostly if it is an
immediate requirement because of the sticker placed
UAssignment of a separate dispensing staff for the high
risk medication to avoid the chaos
UStaff to be motivated to follow the policy guidelines
constantly (by reward etc.)
UReview of the performance after the intervention
UPeriodical review of the policy and the performance
standards
UAdequate staff to be maintained in the pharmacy to
avoid chaos in the department
UKeep the staff educated about the updated policy
UKeep the intranet always active to prevent the delay in
the dispensing of the medications
UAll the high risk medications to be kept at the separate
corner of the pharmacy for easy differentiation (except
narcotics which are in double lock)
UKeep all the high risk medicines at the place where the
insulin refrigerator is placed rather than at the other
corner which is not easily accessible. No chaos will
be observed in this situation after the change
dThe areas to be concentrated to greater extent were
SICU, PICU, CT post, chemo unit,floors (II and III).
dA periodical review is carried out in the hospital after
the intervention to have a broader and comprehensive
study of the implementation intensity of the policy
guidelines with respect to the high risk medications.
dA near to 100% compliance would suggest that the
policy guidelines are been followed in the hospital in
a sustained manner and safe high risk medication prac-
tise can be delivered to the patients of the hospital.
On the whole the compliance of the hospital needed to
be improved with respect to the current status.
MODIFIED POLICY FOR HIGH ALERT
MEDICATIONS
dThe high alert (concentrated electrolytes) must be prescribed
in a separatehigh alert medicationschart in the drug chart
dAll concentrated electrolytes must be stored in the phar-
macy only. They must not be in the patient care areas.
dAll the narcotic drugs must be stored in a double lock
system and two keys with two different nurses
dThe narcotic drugs should be discarded in the presence
of two witnesses in the sink and the empty ampoule
should be sent to the pharmacy in a black cover for
further discarding from the hospital
dThe high risk medications must be administered in the
presence of a witness
dAfter the administration of the high risk medications,
monitoring must be done to check for any adverse events
dAll the high risk medications must be dispensed with
HIGH RISK MEDICATION sticker
Action taken
After understanding the lacunaein the system, high alert policy
was modifi ed and separate stickers were designed to ensure that
all high alert medications are labelled with instructions. Even
few more drugs like insulin, LASA etc were added into the
list to ensure that we have covered all high risk drugs as well.
The same was implemented effectively from October
2011.
164Apollo Medicine 2012 June; Vol. 9, No. 2 Loria

7. Post implementation
A similar study was conducted on the same number of
patients during February 2012eMarch 2012.
The number of errors related to high alert drugs reduced
to 1.2% with respect to focused trainings, labelling, posters,
charts, etc and none of the errors actually reached the
patient.
Reduction of harm from high risk medications Article on Quality 165

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