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High Alert Medications

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MERCY MEDICAL CENTER
Operational Policy
Mercy Hospital Center
Providence Behavioral Health Hospital
POLICY & PROCEDURE

I. Subject:

Policy: MM.7.10-7002
Date: 09 / 06
Code: Pharmacy
Nursing

HIGH RISK / HIGH ALERT MEDICATIONS

II. Policy:
High Alert medications are those agents that pose a high risk of patient harm if not ordered ,
dispensed, administered, processes and/or stored correctly. As such, they should be targeted for
error reduction procedures. The Pharmacy and Therapeutics Committee has reviewed the
hospital’s formulary, past incidents of medication errors and utilization patterns to determine a list
of high-risk/high alert medications. The list of medications is based on a review of previous
medications errors, sentinel events and medications with higher risk for abuse, errors or other
adverse outcomes. High alert medication lists have been reviewed from such organizations as the
Safe Medication Practices (ISMP), United States Pharmacopoeia (USP) and other national data
available on mediation use.



Medications that the Pharmacy and Therapeutic Committee has deemed to be high-risk or
high alert include the following categories and specific agents
1. LASA (Look a line/Sound a like medications

i.e. Insulins (see complete list policy MM.3.20-3105)
2. Investigational Medications
3. Heparin
4. Controlled medications

Schedule II (i.e. Hydromorphone)- V (i.e. Clonazepam and Lorazepam)
5. Non-approved FDA medications
6. Concentrated electrolyte solutions

Potassium Salts ( Chloride, Phosphate and Acetate)

Magnesium Sulfate

Sodium Chloride (> 0.9% conc.)
7. Thrombolytic agents
8. Antineoplastic Medications
9. Narrow therapeutic range medications

Warfarin

Enoxaparin

Digoxin

Amiodarone

Norepinephrine

Epinephrine

Diltiazem

Nesiritide

Esmolol

Doltredecan

Dopamine

Dobutamine

Nitroglycerin

Isoproterenol
page 1 of 2

10. Neuromuscular Blockers
11. Psychotherapeutic medications
12. Iron Dextran
13. Phenytoin and Fosphenytoin
14. Medications new to the hospital or to the market will be evaluated for inclusion in
this list
III. Responsibility:

Pharmacy, Nursing

IV. Procedure:

All high-risk drugs and drugs with a higher potential for dispensing error due to lookalike/sound-alike names, will be stored with a secondary caution label (distinctive colored
auxiliary alert label) thereby alerting staff for the necessity of taking additional dispensing
precautions.

To reduce risk of dispensing errors of high-risk medications the brand and generic name of
the medication will be included on all labels.

High Alert medications stored in automated storage devices (i.e Omnicell) will require a
warning screen following selection and prior to removal to heighten the awareness of the
potential for patient harm.

The generic name of high alert medications is highly recommended on physician’s orders.

The organization will maintain a strict policy for telephone orders that includes a series of
“fail safe” components, such as requiring the trancriber to “read back” the name, dosage
and regimen of the prescribed medication.

Selection of medications for the formulary will emphasize those medications that do
not pose nomenclature problems.

On a minimum of a quarterly basis the Pharmacy and Therapeutics Committee will review
utilization patterns of medications, medication error patterns and other internal data,
together with external data from such organizations as the Institute for Safe Medication
Practices, the United States Pharmacopoeia, the JCAHO and other authoritative sources to
identify any high-risk medication which require special management.
V. Documentation:

N/A

VI. References:

N/A

_________________________________
Patrick Cooke, MD.
Chairman of Pharmacy &
Therapeutics Committee
Mercy Medical Center

__________________________________
Sharon Adams-Babineau, RN
V.P. Patient Care Services
Mercy Medical Center

________________________________
Richard Starzyk, RPH.
Director of Pharmacy
Mercy Medical Center
Date: 12/04
rev: 5/05 , 12/05, 09/06

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