HIGH ALERT Lecture By:PH. Wael Alsorihi

1. HIGH ALERT
PH. Wael Alsorihi

2. Medication Error
High-alert medications are drugs that bear a
heightened risk of causing significant
patient harm when they are used in error.
DEFINITIONOF High-Alert Medications
HIGH ALERT MEDICATION
Errors with these medications are not
necessarily more frequent - just their
consequences may be more devastating.

3. • high-alert medications cause harm more commonly
and the harm is likely to be more serious and leads
to patient suffering and additional cost
Why HIGHALERT MEDICATION

4. COMMON RISK FACTORS
• Poorly written medication orders.
• Incorrect dilution procedures.
• Confusion between IM, IV, intrathecal, preparations.
• Confusion between strengths of the same medications.
• Wrong infusion rate.
• Look alike or sound alike product and similar packaging.
COMMON RISK FACTORS

5. • Based on:
– Previous medication errors
– ISMP, USP and other national data list.
• High alert medications are usually listed in one of
two ways:
1-class/category medications
2-Specific medications
Selection of High Alert Medications
https://www.ismp.org/tools/highalertmedications.pdf

7. Classes/Categories of Medications
Adrenergic agonists I.V (e.g, epinephrine, phenylephrine, norepinephrine ).
Adrenergic antagonists I.V ( e.g, propranolol, metoprolol, labetalol )
Anasthetic agents: inhaled and IV ( e.g, propofol, ketamine )
Antiarrhythmics, I.V ( e.g, lidocaine, amiodarone ).
Anticoagulant : (e.g, heparin, warfarin ).
Chemotherapeutic agents : parentral and oral.
Oral hypogylcemics.
Inotropic medications I.V ( e.g, digoxin , milrinone ).
Moderate sedation agents I.V (e.g, midazolam), Oral (e.g, chloral hydrate)
Narcotics/Opiates I.V, transdermal and oral.
Neuromuscular blocking agents ( e.g, succinylcholine).

8. Specific medications
EPINEPHrine, subcutaneous
Insulin : S.C and I.V.
Magnesium sulfate injection.
Methotrexate : oral ( non – oncologic use ) .
Oxyticin I.V.
Nitroprusside sodium for injection.
Potassium chloride for injection .
Promethazine I.V.
Sodium chloride for injection.

9. COMMON RISK FACTORSTOP FIVE HIGHALERT MEDICATIONS
Ref. ISMP Survey on High-Alert Medications

10. • Factors contributing to harm :
• Insulin & heparin vials kept in close proximity
to each other on a nursing units, leading to mix-
ups
• Pharmacokinetics differ based on insulin type.
• Complex of dosing
• Use of “U” or “IU”
• Frequent monitoring
• Many insulin products available : ( look alike –
sound alike names )
INSULIN

11. Factors contributing to harm :
• Calculation errors.
• IV to PO conversion errors.
• Errors converting potency when changing from
one narcotic to another.
• Many dosage forms.
• Parenteral narcotics stored in nursing areas as
floor stock.
Opiates and Narcotics

12. Factors contributing to harm :
 Mixing pot. chloride/ phosphate
 Request for unusual concentrations
 Unclear labels
Injectable Potassium Chloride or Phosphate

13. Common Risk Factors
• Narrow therapeutic range.
• Complex dosing.
• Frequent monitoring.
• Many interaction
• Unclear labeling regarding concentration and
total volume.
• Multi-dose containers.
• Confusion between heparin and insulin due
to similar measurement units.
Injectable anticoagulant ( Heparin )

14. • Storing sodium chloride solutions above 0.9
percent on nursing units.
• Large number of concentrations/formulations
available.
• No double check system in place.
Sodium chloride solution above 0.9%

15. STRATEGIES TO AVOID ERRORS
INVOLVING HIGH ALERT MEDICATION
 All High Alert Medication containers, product packages and loose vials or
ampoules stored must be labeled as ‘HIGH ALERT MEDICATION’
 All personnel should read the High Alert Medication labels carefully
before storing to ensure medications are kept at the correct place
 All High Alert Medications should be kept in individual labeled containers.
Whenever possible, avoid sound-alike and look-alike drug or different
strengths of the same drug being stored side by side.
 Use TALL-man lettering to emphasize differences in medication name
(eg: DOPamine and DOBUTamine)
STRATEGIES TO AVOID ERRORS INVOLVING HIGH ALERT
MEDICATION

16. CON’T:
Do not use abbreviations when prescribing High
Alert Medications
Specify the dose, route, and rate of infusion for
High Alert Medications prescribed (eg: IV
Dopamine 5mcg/kg/min over 1 minutes)
Do not use trailing zero when prescribing (eg:
5.0mg can be mistaken as 50mg)
STRATEGIES TO AVOID ERRORS INVOLVING HIGH ALERT
MEDICATION

17. CON’T:
 The following particulars shall be independently counter
checked against the prescription or medication chart at the
bedside by two appropriate persons before administration:
Patient’s name and MR
Name and strength of medication
Dose
Route and rate
Expiry date
 Return all unused medication to pharmacy when no longer
required
 Avoid ordering High Alert Medications verbally.
STRATEGIES TO AVOID ERRORS INVOLVING HIGH ALERT
MEDICATION

18. CON’T:
Closely monitor vital signs, laboratory data,
patient’s response before and after
administration of medication
STRATEGIES TO AVOID ERRORS INVOLVING HIGH ALERT
MEDICATION

19. CON’T:
All personal shall be trained prior to handling
of High Alert Medication .
STRATEGIES TO AVOID ERRORS INVOLVING HIGH ALERT
MEDICATION

20. CON’T:
References or dilution guide should be made
available in the wards
Monitor adverse drug reaction and
medication errors related to High Alert
Medications
STRATEGIES TO AVOID ERRORS INVOLVING HIGH ALERT
MEDICATION

21. EXAMPLE:EXAMPLES

23. • Remove or minimize high alert medications from
clinical areas, where possible.
• Using "U" instead of "Units" in physician orders
for heparin and insulin is not accepted.
• Verbal and Telephone orders should be kept to
minimum when prescribing high alert
medications.
Take Home Message