Joint Commission IDs five high-alert meds
Five high-risk medications frequently result in harm to patients, according to a new bulletin released by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Both the Joint Commission and the Huntingdon Valley, PA-based Institute for Safe Medication Practices (ISMP) have identified similar problems with medications.1
The Joint Commission began tracking sentinel events in 1995, reviewing 89 cases related to medication errors so far. The findings are presented in a Joint Commission Sentinel Event Alert about medication errors. (See source box at right for information on how to obtain a copy of the bulletin.)
Another study backs results
Similar findings were found in an ISMP study, the 1996 Benchmarking Project, which culled data on serious medication errors from 161 health care organizations. That report showed that a majority of medication errors resulting in death or serious injury were caused by a specific list of medications. The five "high-alert medications" are as follows:
1. insulin;
2. opiates and narcotics;
3. injectable potassium chloride (or phosphate) concentrate;
4. intravenous anticoagulants (heparin);
5. sodium chloride solutions above 0.9%.
Both organizations found that those five medications — combined with certain situations — repeatedly resulted in errors, producing poor outcomes for patients. The errors could be avoided by implementing specific practices, according to the bulletin. (See chart, "High-alert Medications and Patient Safety," p. 22.)
| High-Alert Medications and Patient Safety | ||
| Drug | Common Risk Factors | Suggested Strategies |
| Insulin | • Lack of dose check systems | • Establish a check system whereby one nurse prepares the dose and another nurse reviews it |
| • Insulin and heparin vials kept in close proximity to each other on a nursing unit, leading to mix-ups | • Do not store insulin and heparin near each other | |
| • Use of "U" as an abbreviation for units (which can be confused with "O," resulting in a tenfold overdose) | • Spell out the word "units" instead of writing "U" | |
| • Incorrect rates being programmed into an infusion pump | • Build in an independent check system for infusion pump rates and concentration settings | |
| Opiates and narcotics | • Parenteral narcotics stored in nursing areas as floor stock | • Limit the opiates and narcotics available in floor stock |
| • Confusion between hydromorphone and morphine | • Educate staff about hydromorphone and morphine mix-ups | |
| • Patient-controlled analgesia (PCA) errors regarding concentration and rate | • Implement PCA protocols that include double-checks of the drug, pump setting, and dosage | |
| Injectable potassium chloride or phosphate concentrate | • Storing concentrated potassium chloride/phosphate outside of the pharmacy | • Remove potassium chloride/phosphate from floor stock |
| • Mixing potassium chloride/phosphate extemporaneously | • Move drug preparation off units and use commercially available premixed IV solutions | |
| • Requests for unusual concentrations | • Standardize and limit drug concentrations | |
| Intravenous anticoagulants (heparin) | • Unclear labeling regarding concentration and total volume | • Standardize concentrations and use premixed solutions |
| • Multi-dose containers | • Use only single-dose containers | |
| • Confusion between heparin and insulin due to similar measurement units and proximity | • Separate heparin and insulin and remove heparin from the top of medication carts | |
| Sodium chloride solutions above 0.9% | • Storing sodium chloride solutions (above 0.9%) on nursing units | • Limit access of sodium chloride solutions (above 0.9%) and remove from nursing units |
| • Large number of concentrations/formulations available | • Standardize and limit drug concentrations | |
| • No double-check system in place | • Double-check pump rate, drug, concentration, and line attachments | |
In addition, here are some general strategies recommended by the Joint Commission:
1. Have systems in place to confirm that the correct patient is getting the correct drug, in the correct dosage, at the correct times, by the correct route.
2. Have policies and procedures for ordering, preparing, dispensing, administering, and monitoring of medications.
3. Review your storage, access, administrations, and patient monitoring procedures to determine whether there is a risk of a medication error. If there is, take steps to reduce the risk.
Reference
1. Cohen MR, Proux SM, Crawford SY, et al. Survey of hospital systems and common serious medication errors. J Health Care Risk Management 1998; 18:16-27.
Single copies of the 1996 Benchmarking Project report are available at no charge. For more information, contact:
• Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Tele phone: (215) 947-7797. Fax: (215) 914-1492. E-mail: [email protected].
The Nov. 19, 1999, Sentinel Event Alert titled "High Alert Medications and Patient Safety" can be found on the Web site for the Joint Commission on Accreditation of Health care Organizations: www.jcaho.org. Or copies can be obtained from the customer service department at no charge. Also, a publication titled Medication Use: A Sys tems Approach to Reducing Errors is available for $60 plus $9.95 for shipping and handling. For more information, contact:
• Joint Commission on Accreditation of Healthcare Organizations, P.O. Box 75751, Chicago, IL 60675-5751. Telephone: (630) 792-5800. Fax: (800) 676-3299 or (302) 678-9200. E-mail: [email protected].
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