High risk medicines resources

Alerts and other information

• WA High Risk Medication Policy (includes use of IV potassium chloride): WA Department of Health
• NSW High-Risk Medicines Management Policy: NSW Ministry of Health (includes use of IV potassium chloride)
• Potassium solutions: IV administration of mis-selected concentrated potassium chloride: UK NHS Improvement
• Patient safety alert: Accidental overdose from intravenous potassium chloride concentrate solutions: UK NHS Improvement
• Safety strategies for potassium phosphates injection: ISMP Canada
• Reducing risk of harm from oral bowel cleansing solutions: UK NHS Improvement

Best practice recommendation

Electrolyte availability MSSA 5.9 (131A) Vials of concentrated forms of electrolytes (e.g. potassium chloride, potassium phosphate, magnesium sulfate, and sodium chloride greater than 0.9%) that require dilution before IV use are not available as ward or imprest stock and/or in automated dispensing cabinets on any patient care units (including in operating room/anaesthesia stock).

OR

(131B) Vials of concentrated electrolytes (e.g. 23.4% sodium chloride used to decrease intracranial pressure, potassium chloride used to stop the heart in cardiac surgery) are restricted to approved patient care units, stocked in limited quantities, segregated from other medicines in secure storage areas, and accompanied by protocols for use and other safeguards (e.g. warning labels).

Monitoring practice tool

• Potassium availability QUM indicator 6.1: Percentage of medication storage areas outside pharmacy where potassium ampoules are available

Alerts and other information

• Sub-cutaneous insulin chart: Australian Commission on Safety and Quality in Health Care
• High concentration insulin products Safety Notice: NSW Health
• Insulin errors: ISMP Canada
• The adult patient’s passport to safer use of insulin: UK NHS Improvement
• Safer administration of insulin: UK NHS Improvement
• Medication Errors with the Dosing of Insulin: Problems across the Continuum: Pennsylvania Patient Safety Authority
• Insulin Measures Worksheet: Pennsylvania Patient Safety Authority

Best practice recommendation

Sliding scale insulin MSSA 5.7 (107) Sliding scale insulin is not used to treat patients with hyperglycaemia. Regular antihyperglycaemia therapy is prescribed to treat diabetics, with supplemental insulin only added to treat hyperglycaemia as necessary in accordance with established protocols.

Alerts and other information

• HYDROmorphone (High-risk medicine): Changes to Dilaudid injectable preparations Safety Alert: NSW Health
• Oxycodone Safety Notice: NSW Health
• Safe use of midazolam Safety Notice: NSW Health
• HYDROmorphone (High-risk medicine) Safety Alert: NSW Health
• Safe storage of accountable medicines Safety Information: NSW Health
• Opioids: Resources for use of opioids for the treatment of pain: SA Health
• Fentanyl skin patches – Safe use Safety Notice: NSW Health
• Fentanyl skin patches: NSW Therapeutic Advisory Group
• Fentanyl skin patches: US Institute for Safe Medication Practices
• Fentanyl skin patches: ISMP Canada
• Fentanyl patch fatalities linked to “bystander apathy”. We ALL have a role in prevention! Institute for Safe Medication Practices (ISMP)
• Advancing opioid safety for children in hospital: Institute for Safe Medication Practices (ISMP) Canada
• Risks with high dose morphine and diamorphine injections: UK NHS Improvement
• Reducing errors with opioid dosing: UK NHS Improvement
• Reducing risk of overdose with midazolam injection in adults: UK NHS Improvement

Best practice recommendations

Sedation antidotes MSSA 5.8 (115) Antidotes for MODERATE SEDATION and PCA/other IV infusion to treat pain and accompanying guidelines for emergency use are readily available near the point of use.

Neuromuscular blocking agent availability MSSA: 5.9 (128A) Neuromuscular blocking agents are not available as ward or imprest stock and/or in automated dispensing cabinets (except in operating room/anesthesia stock).

OR

(128B) If available in critical care units and/or the ED, neuromuscular blocking agents are sequestered from other ward or imprest stock medications (including those stocked in automated dispensing cabinets) and labelled with auxiliary warnings to clearly identify the drugs as respiratory paralysing agents that require mechanical ventilation when used.

Patient controlled analgesia pumps MSSA 6.11 (161) The types of patient controlled analgesia (PCA) pumps used in the hospital are limited to two or less to maximise competence with their use.

Monitoring practice tools

Documentation pain intensity QUM indicator 4.1 (PDF): Percentage of postoperative patients whose pain intensity is documented using an appropriate validated assessment tool.

Written pain management planQUM indicator 4.2 (PDF): Percentage of postoperative patients that are given a written pain management plan at discharge and a copy is communicated to the primary care clinician.

Sedatives at discharge QUM indicator 5.7 (PDF): Percentage of patients receiving sedatives at discharge that were not taking them at admission.

Alerts and other information

• Safe Use of Vincristine Safety Alert: NSW Ministry of Health
• Methotrexate – Improving compliance with oral methotrexate guidelines and safety alert: UK NHS Improvement
• Preventative guidance: Wrong route administration of chemotherapy: UK NHS Improvement
• Dispensing vincristine: Best Practice #1: Targeted Medication Safety Best Practices for Hospitals: ISMP
• Oral chemotherapy – Analysis of incidents: ISMP Canada Safety Bulletin
• Methotrexate: inadvertent daily administration: ISMP Canada
• Fluorouracil RCA analysis – ISMP Canada

Best practice recommendations

Dose calculation MSSA 10.19 (281) Prescribers include the mg/m²dose or area under the curve dose or mg/kg dose with all chemotherapy drug orders. Parameters are periodically reviewed (on at least a weekly basis) for prolonged hospital admissions, as current weight/Body Surface Area (BSA) may differ from admission measurements.

Dose calculation pharmacist independent verification MSSA 10.19 (283) A pharmacist verifies that the mg/m² dose, or area under the curve dose, listed with a chemotherapy order is correct, and documents (eg. with initials or electronically) a double check of the prescriber’s calculated dose (or it is performed electronically) before preparing and dispensing the medicine.

Dose calculation nurse independent double check MSSA 10.19 (285) Nurses permanently document (e.g. with initials or electronically) an INDEPENDENT DOUBLE CHECK of the prescriber’s calculated dose for chemotherapy before administering the medicine.

Drug independent double check MSSA: 10.19 (287) The base solution and all additives (including the drug, dose, volume drawn into each syringe, diluents, actual drug containers) for chemotherapy admixtures or compounded oral solutions are INDEPENDENTLY DOUBLE CHECKED by a pharmacist or a nurse (even if initially prepared by a pharmacist) and documented (e.g. with initials or electronically) before they are added to the final product.

Monitoring practice tool

Protocol based chemotherapy QUM indicator 3.6: Percentage of patients receiving cytotoxic chemotherapy whose treatment is guided by a hospital approved chemotherapy treatment protocol.

Alerts and other information

• Non-vitamin K antagonist oral anticoagulant (NOAC) Guidelines: Clinical Excellence Commission (CEC) 2016
• Newer oral anticoagulants (update) Safety Notice: NSW Health
• Warfarin (revised) Safety Notice: NSW Health
• New oral anticoagulants Safety Notice: NSW Health
• Unfractionated Heparin: ISMP Canada
• Heparin-induced thrombocytopenia: ISMP Canada
• Actions that can make anticoagulant therapy safer: UK National Patient Safety Agency
• Appropriate anti-coagulant use: ISMP Canada
• Preventing error relating to commonly used anticoagulants: The Joint Commission

Best practice recommendation

• Medication Safety Self Assessment for Antithrombotic Therapy in Australian Hospitals

Alerts and other information

• Inadvertent wrong route injection: Identification of Post-Injection Syndrome Olanzapine Pamoate Long Acting Injection Safety Notice: NSW Health
• Wrong route errors with oral medication Safety Notice: NSW Health
• Wrong route administration audit tool: Victorian Department of Human Services
• Correct identification of medication and solutions for epidural anaesthesia and analgesia Safety Notice: NSW Health
• Promoting safer measurement and administration of liquid medicines via oral and other enteral routes: UK NHS Improvement
• Lowering the risk of medication errors: Independent double checks for patient controlled analgesia: ISMP Canada
• High alert drugs and infusion pumps: Extra precautions required: ISMP Canada

Best practice recommendations

Use of oral syringes MSSA 6.11 (157) Specially designed oral syringes, which cannot be connected to IV tubing, are used for dispensing/administering oral liquid solutions.

Use of infusion pumps MSSA 6.11 (166) General infusion pumps with SMART PUMP TECHNOLOGY are in use with full functionality employed to intercept and prevent wrong dose/wrong infusion rate errors due to misprogramming the pump, miscalculation, or an inaccurately prescribed dose or infusion rate.

Epidural infusion pumps MSSA 6.11 (171) Only one type of epidural infusion pump is used and is different from general infusion devices used in the organisation.

Use of bar-coding at point-of-care MSSA 10.19 (295) If bar-coding at the point-of-care is used for medication administration, an interdisciplinary team reviews metrics from the system, including the percent of medicines with a readable barcode, scanning compliance rates, and bypassed or acknowledged alerts, and any barriers associated with using the technology are addressed to maximise the safe use of the system.