April 24, 2017

3 Ways to Help Minimize Harm from High-Alert Medications

According to the Institute for Safe Medication Practices (ISMP) Canada, high-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error.

Although mistakes may not be more common with these drugs, the consequences of an error are more devastating to patients, which is why prevention is of ongoing importance.

During the Ontario Hospital Association’s Drug Oversight, Safety, and Understanding the Opioids Epidemic conference held on March 22, 2017, presenters shared their tips for healthcare providers to help reduce incidents arising from high-alert medications:

1. Report potential or actual incidents

According to Spencer Ross, Program Lead, Pharmaceuticals, at the Canadian Institute for Health Information (CIHI), anonymously reporting potential and actual medication/IV fluid incidents to the National System for Incident Reporting (NSIR) can go a long way to promote safe medication management.

“The information submitted by acute and long-term care facilities is used by such entities as Health Canada and the Institute for Safe Medication Practices (ISMP) Canada to identify areas of concern and the need for potential changes by drug manufacturers, as well as informing stakeholders on trends emerging from incident reports,” said Mr. Ross. “By collecting this information, we are better able to learn from each other and endeavour to improve patient outcomes.”

2. Use independent double check

Marg Colquhoun, a consultant with ISMP Canada warned of the risks of overrelying on technology and the continued important role of independent double checks.

“Relying on technology can result in complacency and the double-check process helps keep that in check,” said Ms. Calquhoun. “We must provide hospital staff with ongoing assistance to ensure they understand the risks and have the tools and knowledge to mitigate medication errors.”

The power of this risk reduction strategy for high alert drugs is based on the principle that two people are unlikely to make the same mistake when working independently. For example, Patient X has an order to receive insulin by sliding scale.  The nurse looking after patient X checks her patient’s blood sugar, and prepares the required dose of insulin.  The nurse performing the independent double check reviews the patient’s Medication Administration Record (MAR) for the insulin sliding scale order, confirms that the dose has been prepared for the correct patient, reviews the blood sugar result and determines the type of insulin and the dose of insulin that should be prepared and then checks the vial of insulin (that the dose was prepared from) as well as the dose of insulin in the syringe.  Finally, the nurse confirms the route of administration (in this case subcutaneous).


3. Engage patients
Based on findings from an ISMP Qualitative study on 17 critical incidents, lack of patient engagement to validate or clarify previous use of a drug was a factor in 30% of the incident reports. “Engaging patients is crucial to improved outcomes as they, and their caregivers, can be keen observers of the effects of drugs,” noted Ms. Colquhoun.