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High-Alert Medications

Defined as drugs having a higher


likelihood of causing injury if misused
Are drugs that bear a heightened risk
of causing significant patient harm when
they are used in error.
Some high-alert medications also have
a high volume of use, increasing the
likelihood that a patient might suffer
inadvertent harm.
MEDICATIONS are deemed
high alert not because they
are more prone to errors than
other medications but
because of the serious harm
that can result from
administering the drug error.
In 1993, certain medications
were tagged as todays
poisons. JCHO has made
one high-alert medication a
priority by including it in one
of its patient-safety goals
Some of the measures implemented to
prevent problems with high-alert
medications are:
Limit availability of medication
Utilize double checks; it can occur at the
dispensing or administering point of the
medication-use process.
Utilize caution labels
Review storage practices for those items
that must remain available for use
Standardize ordering procedures; use
pre-printed orders when possible


Some of the measures implemented to
prevent problems with high-alert
medications are:
Require double check calculations
Use only pumps that are protected from
free flow
Implement maximum dosing alerts in
pharmacy computer systems
Develop standards for monitoring of
some high-alert medications
Prohibit bolus doses from infusion bags.
(3) Principles to improve high-alert
medication administration and
distribution:

1.) Eliminate the Possibility of Error

2.) Make Errors Visible

3.) Minimize the Consequence of Error

1. Eliminate the Possibility of Error
Reduce the number of
drugs on a facilitys
formulary.
Reduce the number of
concentrations and
volumes
Remove high-alert drugs
from critical areas

2. Make Errors Visible
Have two individuals
independently check the
product to ensure it is
correct, particularly when
received in bulk.
Have two individuals
independently check
equipment settings, as
applicable, since some
drugs are administered IV.
3. Minimize the Consequence of Error
Minimize the size of vials or
ampules in the patient-care
area to be able to give the
dose commonly needed.
Reduce the total dose of
high-alert drugs in
continious IV drip bags.
Reduce the concentration
of the drugs when possible.
Based on these principles, fostering
change in the way high-alert drugs are
managed includes things such as:
Encouraging standardized dosing procedures;
Carefully screening new products; and
Creating system redundancies, commonly
known as double checks

The US FDA defines a drug product as
having a narrow therapeutic ratio as
follows:
A. There is less than a 2-fold difference in
median lethal dose and median effective
dose values.
B. There is less than 2-fold difference in the
minimum toxic concentration and minimun
effective concentrations in the blood.
C. Safe and Effective use of the drug products
requires careful titration and patient
monitoring.
QUESTION:
1. What are the reasons why certain
medications are deemed high alert?

Answer:
High-alert (or high-hazard) medications are
medications that are most likely to cause
significant harm to the patient, even when
used as intended. Although any medication
used improperly can cause harm, high-alert
medications cause harm more commonly and
the harm they produce is likely to be more
serious and leads to patient suffering and
additional costs associated with care of the
patients.

QUESTION:
2. What are the methods of preventing errors
in the administration of the high-alert
medications and narrow therapeutic index
drugs?

Answer:
Health information technology has been
identified as method to reduce medication
errors as well as improve the efficiency and
quality of care.
Computerized physician order entry and
clinical decision support systems can play a
crucial role in decreasing errors in the ordering
stage of the medication

QUESTION:
3. What are the technologies used to minimize
high alert medication errors?

Answer:
Bar code technology, intravenous infusion
safety systems, and electronic medication
administration records can target prevention
of errors in medication dispensing and
administration

QUESTION:
4. What are the other agents considered as
High Alert Medications?

Answer:
top high-alert medications to be insulin,
opioids, injectable potassium chloride (or
phosphate), intravenous anticoagulants
(heparin), and sodium chloride solutions
Other high-alert medications include
chemotherapeutic agents and sedatives.

QUESTION:
5. What are the organizations offering safe
medication practices?

Answer:
American Society of Health-System
Pharmacists
They have offer an extensive information for
patients page which offers tips and tools for safe
medication practices and step-by-step instructions
on how to administer the different forms of
medication.
Be MedWise
On this website, patients can find educational
resources for successfully managing and
understanding their medications.


Drug Digest
DrugDigest is a noncommercial, evidence-based,
consumer health and drug information site
dedicated to empowering consumers to make
informed choices about drugs and treatment
options.
US Pharmacopoeia (USP)
USP Offers:
definitions of medical and drug terminology
articles on medication errors in various settings,
medication safety initiatives, and the impact of
practitioner experience on official drug standards-tools
such as USPs Drug Error Finder, a free tool for
accessing lookalike/soundalike drug names


alerts on specific drug products based on medication
error reports
patient safety newsletters (USP Drug Safety Review,USP
Medication Safety Review, Error Watch, USP Quality
Review)

HIGH-ALERT
MEDICATION DRUGS
1. Adrenergic Agonist
EPINEPHRINE
Availability:
10 mL saline.
Maintenance: 500mcg/dose 6
times a day
Pharmacologic Category:
Cardiac Stimulant

NOREPINEPHRINE
Availability:
4mcg/mL by IV Infusion
Pharmacologic Category:
Vasoconstrictor
2. Adrenergic Antagonists
PROPOFOL
Availability:
Continuous infusion: 4-
12mg/kg/hr
Repeat bolus inj: 25-50 mg
Pharmacologic Category:
Anesthetics

METOPROLOL
Availability:
100 mg tablet
Pharmacologic Category:
Beta Blockers



3. Insulin & other
Antidiabetic Drugs
INSULIN
Availability: IM or SC inj. Individualized dosage
Pharmacologic Category: Anti-diabetic



METFORMIN
Availability:
500 mg Oral Tablet
Pharmacologic Category:
Antidiabetic

MINIDIAB
Availability:
5 mg Oral Tablet daily
Pharmacologic Category:
Antidiabetic

4. Cardiac Drugs
DIGOXIN
Availability:
Usually 125-250 mcg/day
Pharmacologic Category:
Cardiac Glycoside

AMIODARONE
Availability:
200 mg tablet
Pharmacologic Category:
Cardiac Arrhythmia

5.Warfarin and Clopidogrel
WARFARIN
Availability:
Oral Tablet 2-10mg daily
Pharmacologic Category:
Anticoagulant / Antiplatelet

CLOPIDOGREL
Availability:
Film Coated Tablet 75mg daily
Pharmacologic Category:
Anticoagulant / Antiplatelet

What are narrow therapeutic drugs?
Narrow therapeutic index (NTI) drugs are
agents for which small changes in
systemic concentration can lead to
significant changes in pharmacodynamic
response
What are the concerns for drugs with
narrow therapeutic indices?
By definition, approved drugs
with narrow therapeutic
indices exhibit small
intrasubject variability.

If this were not true, patients
would routinely experience
cycles of toxicity and lack of
efficacy, and therapeutic
monitoring would be useless.

ACTIVITY
Narrow Therapeutic
Drugs
1. Digoxin
Availability & Dose: 250 mcg
>10 year old Rapid oral loading dose
750-1500 mcg as single dose
Slow oral loading dose 250-750 mcg
daily for one week followed by an
maintenance dose
Maintenance dose: Usually 125-250
mcg/day
Pharmacologic Category: Cardiac drug
2. Heparin
Availability & Dose: 1000 IU/mL
Treatment of venous thromboembolism
IV loading dose of 5000-10,000 u 12hrly
Children Lower loading dose then maintenance with
continuous infusion of 15-25u/kg
Pharmacologic Category: Treatment and prophylaxis of
thromboembolism
Availability & Dose: 100mg,50mg/mL
Adult Initially 100mg tid
Children Initially 100mg tid, adjusted
Status Epilepticus 10-15mg/kg slow IV
Maintenance: 100mg orally or IV 6-
8hrly
Cardiac Arrhythmia 3.5-5mg/kg once
Pharmacologic Category:
Anticonvulsant
Availability & Dose: 130mg
Adult 1 tab tiq-qid
Children 7-12 yr tab tid- qid
Pharmacologic Category:
Antiasthma
Availability & Dose: 1mg, 2.5mg, 5 mg
Induction 10mg daily and adjusted
according to prothrombin time
response
Elderly lower doses
Maintenance 2-10mg daily

Pharmacologic Category:
Antithrombotic

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