Hospitals told how to ease high-alert problems

Hospitals told how to ease high-alert problems

A report in the Joint Commission Journal on Quality and Healthcare Safety makes recommendations for hospitals to follow to reduce patient harm related to high-alert medications. The report comes from the Institute for Healthcare Improvement in Cambridge, MA, and gives specific recommendations for anticoagulants, sedatives, narcotics, and insulin.

Improving safety when using anticoagulants:

• Have formatted anticoagulation flow sheets and orders follow patients through transfers from hospital to skilled nursing facility to home;
• Establish an anticoagulant dosing service or clinic for both inpatient and outpatient care;
• Report laboratory results to a provider who can act on them;
• Permit pharmacists to change doses of antithrombotic agents based on laboratory values by following protocols approved by medical staff;
• Limit warfarin starting doses to 2.5 mg or 5 mg depending on patient age and/or comorbidities; and
• Check medication orders for drug interactions.

Improving safety when using heparin:

• Establish and implement standardized protocols and dosing;
• Develop guidelines to hold heparin and give reversal treatment of heparin overcoagulation; and
• Reduce the potential for errors and simplifying the process by minimizing the number of available concentrations.

Improving safety when using warfarin:

• Use standardized protocols include vitamin K dosing guidelines when starting and maintaining warfarin therapy;
• Develop an evidence-based protocol to discontinue and restart warfarin perioperatively;
• Make laboratory results available on the unit within two hours or monitoring at the bedside;
• Plot international normalized ratio results versus dose changes on the run chart or control chart; and
• Have patients and families participate in self-management.

Improving safety when using narcotics:

• Standardize protocols to begin and maintain pain management;
• Ensure appropriate monitoring to detect adverse effects of narcotics and opiates;
• Make available protocols and reversal agents that can be given without needing additional physician orders;
• Minimize or eliminate multiple drug strengths when possible;
• Consult pain specialists (specially trained nurses, pharmacists, physicians, or others) when managing physicians are not experienced in pain management;
• Maximize nonpharmacologic intervention for pain and anxiety;
• Have pharmacy or nursing staff program and independently double-check all pumps; and
• Independently double-check patient-controlled analgesia and epidural narcotics on the unit.

Improving safety when using insulin:

• Independently double-check the drug, concentration, dose, pump settings, route of administration, and patient identity before administering any intravenous insulin;
• Use pretyped forms for diabetic and insulin infusion orders;
• Separate look-alike and sound-alike drugs by labeling, time, and distance;
• Prepare all infusions in the pharmacy and standardize them to a single concentration of intravenous infusion insulin;
• Encourage patients who are able to manage their own insulin; and
• Coordinate meal and insulin times.

Improving safety when using sedatives:

• Stock and prescribe only one concentration of oral agents for moderate sedation;
• Use preprinted order forms for narcotics and sedatives;
• Monitor all children who have received chloral hydrate for preoperative sedation before, during, and after the procedure; and
• Make available age- and size-appropriate resuscitation equipment and reversal agents during procedures performed when a patient is sedated and in other situations where sedatives are administered.