Professional Documents
Culture Documents
Policy Number:
3364-100-70-13
Department:
Hospital Administration
Approving Officer:
TOLEDO
Ifl72
Responsible Agent:
Scope:
(A)
Policy Statement
The Pharmacy and Therapeutics Committee, has reviewed the hospitals formulary and trend analysis of medication en'ors to
determine a list of high-risklhigh alert medications. Additional input is incorporated from such organizations as the Institute for
Safe Medications Practices (ISMP, United States Pharmoacopoeia (USP) and other national databases repOlting information on
the use of medications.
Opiates
.:.
.:.
Chemotherapeutic Agents
.:.
Anticoagulants
.:.
Insulin
.:.
.:.
(C)
Procedure
The following processes will be employed in the handling of high-alert medications include, but are not limited to, the
following:
OPIATES
.:.
.:.
Opiates and all other controlled substances shall be maintained under locked storage in both the Pharmacy Depmtment
and patient care units .
Documentation and reconciliation of controlled substance usage will follow all applicable state and federal standards .
.:.
.:.
.:.
Policy 3364-100-70-13
High Alert Medications
Page 2
INSULIN
.:.
.:.
.:.
Prior to administration, it is recommended that the insulin volume be checked by two R.N.s .
Insulin is dispensed to individual patients .
Long acting insulin is drawn up by pharmacy and provided in unit of use
Policy: Nursing Policy Administration ofIntravenous Medication 3364-110-5-02
CHEMOTHERAPY AGENTS
.:. Dose Calculations are checked by two R.N.s .
.:. Nursing staff must be qualified to administer IV chemotherapy.
.:. Emergency Medications and equipment is available for immediate intervention .
.:. Order entry and calculations are checked by 2 pharmacists, product checked in compounding hood by pharmacist
.:. Orders must be written by attending physician or a fellow. No Verbal orders are allowed (Policy 3364-100-70-07).
Policy: Nursing Policy Admin. of Intravenous Medication 3364-110-5--02
Nursing Policy Qualificationsfor Nurses to Administer IV Antineoplastic Chemotherapy 3364-110-5--08
Nursing Policy Administration of Antineoplastic Chemotherapy 3364-110-5--07
Nursing Policy Admin. Of chemotherapy with a Known Potential for Hypersensitivity Reactions 3364-110-5--09
Hospital Policy 3364-100-70-07 Ordering ofAnti-Neoplastic Agents
Pharmacy Policy Antineoplastic Agents3364-133-24
Safety Manual HM 08-005
ANTICOAGULANTS
.:.
.:.
.:.
.:.
LOOK-ALIKE-SOUND-ALIKE MEDICATIONS
.:. Products are segregated in the Automated dispensing cabinets (ADC)
.:. Narcotics are segregated in the Pharmacy narcotic safe
.:. High Alelt Medications are identified in the ADC with "Alert" stickers
Approved by:
I.
di-d~-</(____
~
CJ
Scott Scarborough, PhD
Interim Executive Director and Sr. Vice President
for Finance and Administration
ReviewlRevision Date:
8/10/2005
11126/2008
412712011
Date
Date
4/1/2014