Practical Approach to Prevent High Alert Medicines Related Errors in Tertiary Care Hospitals

Sachin Raval*1

1 Apollo Hospitals international limited, Ahmedabad-India.

*Corresponding Author: Sachin Raval, Apollo Hospitals international limited, Ahmedabad-India, TEL: 07698815153; FAX: 07698815153;

Citation: Sachin Raval (2018) Practical Approach to Prevent High Alert Medicines Related Errors in Tertiary Care Hospitals. Medcina Intern 2018 2: 124

Copyright: :© 2018 Sachin Raval, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Received date: October 24, 2018; Accepted date: November 05, 2018; Published date: November 08, 2018.


High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Most medications errors are occurring due to these drugs. The Institute for Safe Medication Practices (ISMP) reports that the incident rates of this group of medicines may not necessarily be higher than the other medicines but when incidents occur the impact on the patients would be serious (significant). Concentrated electrolytes, Heparin, Insulin, Chemotherapy, Narcotic, LASA Medicines are under the high alert medicines.

This may include strategies like limiting access to these medications, using auxiliary labels and automated alerts, standardizing the ordering, preparation, and administration of these products, and employing automated or independent double checks when necessary. Preventing the harm from high alert medications: Awareness, readiness, education: Training arranged for nursing, pharmacists and doctors for high alert medication; develop list for high alert medications and show cash in every wards/ICUs. Strategy like Double check, High alert labels with indications, High alert exhibition near nursing office for awareness, Double signature, Store in different locations in wards/ICUs and Pharmacy, Involve the patient & family: Patient counseling in case of insulin. Provide patient education at literacy level understandable by all.

As per guidelines of The Institute for Safe Medication Practices (ISMP) we have taken following initiative in our organization.

Identify High alert medication list.

• Concentrated electrolytes. (Inj. Potassium chloride, Inj Magnesium sulphate 50%, Inj Potassium Phosphate, NS 3%)

• Insulines

• Narcotics

• Chemotherapy

• Heparin

• LASA (Look alike and sound alike medications)

Concentrated Electrolytes. (Inj. Potassium chloride, Inj Magnesium sulphate 50%, Inj Potassium Phosphate, NS 3%)

Precaution while Storage/Dispensing/Administration

• Separate storage in Pharmacy.

• Special High alert label with indications.

• Daily Audit of concentrated electrolyte in newly made in house software • No storage in Patient care area.

• Separate written space in drug chart. Figure 1.

Figure 1


Precaution while Prescribing/Storage/Dispensing/Administration

• Store in Refrigerator (2-8) and after first use store below 25 temperatures.

• Follow “Do not use abbreviation” while prescribing.

• Special High alert label with indications.

• Separate diabetic chart in ICU and Ward.

• Separate storage in wards/ICUs.

• Classification (Long acting, short acting, rapid acting) of Insulines must be consider while administration.

• Double signature while administration.

• Strict follow open on and discard rules. (28 days as per guidelines)

• Educating patients at the time of discharge and also from OP Pharmacy for insulin pen.

• Transfer reconciliation is monitor closely to evacuate errors related miscommunication during transfer of patients. E.g. blood glucose monitoring, infusion therapy

• We are using sliding scale implementation for better coordination between doctor and nursing.

• Educate to the nursing for different. Figure 2.

Figure 2


Precaution while Prescribing/Storage/Dispensing/Administration

• Special privileges given to consultants for prescribing Narcotics. Doctor registration number must write in prescription.

• Separate Narcotic prescription for prescribing.

• Triplicate copy of prescription uses for narcotic drugs.

• Nurses maintain administration record in red narcotic register.

• Double lock cabinate for narcotic storages.

• No ward stock of narcotic in any wards, only stock available in ICUs/OT/Endoscopy and Emergency.

• Monthly audit by pharmacy team.

• Maintain patient wise details in pharmacy for narcotic usages.

• Handing over of nurses after narcotic usages.

• Discarded unused ampoules in presence of two witnesses.

• Dispense only against empty ampoules of narcotics. Figure 3.

Figure 3


Precaution while Prescribing/Storage/Dispensing/Administration

• Strict weight base prescription writing by oncologist.

• Follow chemo protocol while dispensing, preparing, administration, monitoring.

• 4 stack holder signature in chemo protocol. Consultants, Medical officer, Clinical Pharmacist and Nursing.

• Follow weight base drug calculation through proper guidelines.

• Separate admixture room for chemotherapy admixture.

• Admixture done by clinical pharmacist only throughout hospitals.

• To follow aseptic technique while admixture.

• Double signature and checking while administration. Figure 4.

Figure 4


Precaution while Prescribing/Storage/Dispensing/Administration

• Separate label for Heparin with indication.

• Double sign for administration.

• Separate storage in Pharmacy, wards/ICUs.

• Monitoring incase of Heparin infusion.

• Dose confirmation for 5000 international unit and 25000 international unit. (5000 and 25000 international unit are available in 5ml vial) • Monitor drug interaction between other anticoagulants.

• Risk assessment for hemorrhage. Figure 5.

Figure 5

LASA (Look alike and Sound alike medications.

Precaution while Prescribing/Storage/Dispensing/Administration

• LASA List developed by D & T Committee on basis of research and incidents.

• Separate High alert label for LASA Medicines with indications.

• Separate storage in Pharmacy, wards/ICUs. (Two different place for storage of LASA Drugs)

• Double checking and double signature while administration.

• LASA Medicines poster display near pharmacy and nursing punching place.

• LASA, High alert medicines items display near nursing punching place. Figure 6,7.

Figure 6
Figure 7

PAT (Prescription audit team):

• Audit by clinical pharmacist after prescription by doctor in drug chart

• Online prescription audit by pharmacist with demographical parameter and laboratory investigations.

• Checking for rationality of prescription by ward round. • Audit with 7 parameters by PAT team as follows,

Process contained some points as follows:

1) Online pharmacist for 24 x 7.

2) Target for 100% medication reconciliation with PAT verification.

3) Revised process for appropriateness review.

4) Ward pharmacist with CUG number.

5) Telephonic intimation and text messages for ward pharmacist for new Admission, new or change in prescription, discharge patients.

6) Restriction for nursing to indent medicine before PAT (Prescription Audit Team) verification.

7) Pharmacist ward round with consultant. Figure 8.

Figure 8