High Alert Medications, Slides of Pharmacy

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High Alert Medications

Basic Medication Safety (BMS) Certification Course King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard – Health Affairs

Learning Objectives

 Define and identify High Alert Medications

 Share our experiences / reporting

 Identify common risks

 Outline strategies to improve and minimize risks

 Reinforce policy & procedures

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Top 10 Medications Reported as Causing Harm

MedMarx 2008 High Alert Meds with Harm Score E and Above

(43%) Harmful Incidents.^ Accounted for 199 / 465 (ISMP Canada; 2001-2005)

Reported Medication Errors / Near Misses for Top Four High Alert Medications

2015, 2016 and 2017 - Central Region (KAMC)

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Antithrombotic Agents

Opiates/Narcotic Agents

Chemotherapeutic Agents

Insulin

2015 2016 2017

Total HAM:  2015 = 527  2016 = 814  2017 = 814

Half of Preventable ADEs involve:

Winterstein, A., Hatton, R., Gonzalez-Rothi, R., Johns, T., & Segal, R. (2002). Identifying clinically significant preventable adverse drug events through a hospital’s database of adverse drug reaction reports. Am. J. Health Syst. Pharm., 59(18), 1742–1749. Retrieved from

Institute of Medicine. Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors, Washington, DC: The National Academies Press 2006.

U$3.5 billion is spent annually on extra medical costs of ADEs

DRUG TOO MUCH LEADS TO: Opiates Respiratory depression Insulin Hypoglycemia Anticoagulants Bleeding

Case:

 44 year old male  History of PE on Warfarin

 Admitted for bilateral hydronephrosis, with acute renal failure for bilateral nephrostomy tube placement  Post-nephrostomy tube the anticoagulation was resumed with Enoxaparin 120 mg q 12 hr in the setting of severely compromised renal function

 Patient was transferred to ICU with clinical picture of shock, which turned to be hemorrhagic, complicated by multi-organ failure and death

 Ultrasound of abdomen showed evidence of intra-abdominal collection

Anticoagulants

Common Strategies

 Standardize labels, packaging  Protected Standard Concentration  Anticoagulation Services  Counseling  Use protocols / smart pumps  Individualized monitoring and handoffs  Medication Reconciliation  Improved Information and Counselling for Patients  At start of therapy (prescription)  On hospital discharge  At the first anticoagulant clinic appointment  When necessary throughout course of therapy

Opiates

Percentage of Reported High Alert Medication Events

 24% during 2017 at KAMC – Riyadh  23% during 2016 at KAMC – Riyadh

Common Risks

 LASA (Morphine and HYDROmorphone)  Lack of leading zero  Ordered .8 mg , patient received 8 mg Morphine  Bolus dose, failing to re-program maintenance dose  Different rates and concentrations  Improper disposable of Transdermal Patches

Chemotherapy

Percentage of Reported High Alert Medication Events

 18 % during 2017 at KAMC-Riyadh  15 % during 2016 at KAMC-Riyadh

Cases

Drug Error and Outcome Methotrexate Administering daily instead of weekly (approximately 25 fatalities reported) VinCRIStine Accidental Intrathecal administration - Fatal Lomustine Oral agent administered daily instead of every 6 weeks, hospitalization and death CARBOplatin and CISplatin

CISplatin administered at dose intensity appropriate for CARBOplatin, fatal outcome

Chemotherapy

Common Risks

 Miscommunication  Total course (or cycle) dose given every day  Substantial distance between Pharmacy and patient treatment area (lack of communication)  Lack of health care information (labs, BSA)  Excessive interruptions  LASA / packaging  Lack of protocols and education  Route of administration: Intravenous vs. Intrathecal

Chemotherapy

Common Strategies: Cont.

 Use of personal protective equipment to reduce employee exposure to hazards  Dispense Vin CRISt ine (and other vinca alkaloids) in a minibag of a compatible solution and not in a syringe  Weekly dosage regimen default for oral Methotrexate in electronic systems when medication orders are entered.  Body Surface Area dosing (mg / m2), when applicable mg / kg  Use updated lab information  Patient / caregiver education  Communication

Insulin

Percentage of Reported High Alert Medication Events

 8% during 2017 at KAMC Riyadh  13% during 2016 at KAMC Riyadh

Common Risks

 Look-Alike Vials  Use of “U” or “IU”  Incorrect dose / rate  Lack of dose checking

Concentrated Electrolytes

Common Risks

Concentrated Electrolytes

Common Strategies

 Stored in Red Bins with Lids  Patient care areas: Stored in ADC locked Lidded  Crash Cart / Black Box (as applicable)  Auxiliary label “High Alert / Conc. Electrolyte: Must Be Diluted”  Standardized medication labels

APP 1433-18: Concentrated Electrolytes