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.
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