High-Alert Med - Northwell Health

North Shore-Long Island Jewish Health System
Long Island Jewish Medical Center
POLICY TITLE: High-Alert Medications
Prepared by:
Effective
System Pharmacy & Therapeutics
Date: 1/04
Committee
PATIENT CARE MANUAL
Last Reviewed / Revised:
1/04, 10/07, 11/08, 5/10,
4/12, 9/13, 7/14
Total
Pages:
10
GENERAL STATEMENT OF PURPOSE:
High-alert medications are those drugs that bear a heightened risk of causing significant patient
harm when used in error. Though mistakes may or may not be more common with these agents,
the consequences of such an error carry the potential for devastating outcomes.
The Joint Commission (TJC) Medication Management (MM) standards require institutions to
identify, in writing, its high-alert medications, develop a process for managing high-alert
medications, and implement its process.
POLICY:
Identify and review a list of high-alert drugs specific to the North Shore – LIJ Health System.
This list will be used to ensure that safeguards are put in place to prevent medication errors and
protect the patient.
SCOPE:
This policy applies to all members of the North Shore – LIJ Health System work force but not
limited to employees, business associates, medical staff, volunteers, students, physician office
staff, and other persons performing work for or at North Shore – LIJ Health System.
PROCEDURE / GUIDELINES:
• The System P&T Committee has agreed to designate the following drug pairs as North Shore
– LIJ Health System high-alert medications (see Appendix I).
• Requests to add or remove agents from this list will be directed to the System P&T
Committee.
• The ultimate decision to modify this policy shall lie with the System P&T Committee
membership.
• Due to differing medication management processes at each Health System site and the
implementation of various technology solutions, the exact strategies (i.e. processes) for
managing high-alert medications shall be determined by local P&T Committees (see
Appendix II). Recommended strategies may include, but are not limited to:
Ø Standardizing the ordering, storage, preparation, and administration of these products
Ø Improving access to information about these drugs
Ø Limiting access to high-alert medications
Ø Using auxiliary labels and automated alerts
Ø Employing redundancies such as automated or independent double-checks
Document:
Reviewed/Revised Date:
Supersedes:
High-Alert Medications
July 2014
September 2013
Page 1/10
LIJMC HIGH-ALERT MEDICATION MANAGEMENT STRATEGIES:
Storage:
ü Auxiliary labels and other visual cues (e.g., red bins) are used to identify high-alert agents
whenever possible
Transcription / Ordering:
ü High Alert Medications approved by the System P&T Committee will be configured in
Enterprise Sunrise.
• All adult orderables for these agents will be flagged as ‘High Alert’ to alert all health care
providers.
Preparing / Dispensing:
ü Concentrations and/or doses are standardized whenever possible
Administration:
ü Smart pumps are utilized for continuous IV infusions whenever possible
ü Administration guidelines are standardized (e.g., IV admixture guide)
Monitoring:
ü Continuous tracking, trending and analysis of suspected drug reactions and medication errors
are performed.
ü Assessment of the effectiveness of the implemented high-alert medication strategies in the
promotion of patient safety via the prevention of medication errors is ongoing through both
the Medication Safety and the Pharmacy and Therapeutics Committees.
ü Reporting of suspected drug reactions and medication errors to the Department of Quality
Management and the Performance Improvement Coordinating Group is maintained on a
monthly basis, with appropriate action taken as necessary.
REFERENCES:
The Joint Commission’s Hospital Accreditation Standards – Medication Management
ISMP’s List of High-Alert Medications
Document:
Reviewed/Revised Date:
Supersedes:
High-Alert Medications
July 2014
September 2013
Page 2/10
Reviewed / Approved by: LIJMC Pharmacy & Therapeutics Committee
Reviewed / Approved by: LIJMC Medical Board
SIGNATURES:
X
07/09/14
07/22/14
Date:
Richard Schwarz, Medical Director (LIJ)
X
Date:
Margaret Murphy, Chief Nursing Officer (LIJ)
X
Date:
Joseph Simpson, Chair, Pharmacy & Therapeutics Committee (LIJ)
X
Date:
Dana Rucco, Director of Pharmacy Services (LIJ)
X
Date:
Blaine Greenwald, Acting Medical Director (ZHH)
X
Date:
Mary Beth McManus, Associate Executive Director I, PCS (ZHH)
X
Date:
Neil Kremen, Chair, Pharmacy & Therapeutics Committee (ZHH)
X
Date:
Anthony Longo, Director of Pharmacy Services (ZHH)
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Reviewed/Revised Date:
Supersedes:
High-Alert Medications
July 2014
September 2013
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July 2014
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July 2014
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Supersedes:
High-Alert Medications
July 2014
September 2013
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