By: Suzan R. Miller-Hoover DNP, RN, CCNS, CCRN-K
Adverse medication events continue to occur despite the efforts of the Institute of Safe Medication Practice (ISMP) and other regulatory agencies efforts to reduce these untoward events. High-risk medications top the list of drugs in moderate to severe untoward events (Diabetesincontrol, 2013; ISMP, 2018).
What are high-alert medications? The ISMP defines these medications as “…drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients” (Institute of Safe Medication Practices (ISMP), 2018).
The ISMP has been providing healthcare facilities with a list of annually up-date high-risk medications; the Joint Commission requires that facilities compile a list of high-risk medications and develop and implement a process to manage these medications.
Despite these standards, healthcare facilities continue to have high-risk medication lists that are not well-thought out and their strategies for error prevention are not robust. A high-risk medication list is relatively useless without a robust risk-reduction process.
Strategies to consider making your institution’s process more vigorous:
• Not every high-risk medication on the ISMP list is meant to be on an individual facility’s high-risk medication list.
o Thoughtfully review safety events and compare to the ISMP to ensure that the medications on your list are relevant
• Double signatures do not equate to the medication being independently doubled checked
o Unless the double check is done independently by two staff members, compared for accuracy, and then double signed, it will not decrease the risk of error.
• Ensure that the label matches the bag of fluid
o Bar scanning the label only indicates that the label is correct for the patient; however, if the label is placed on the wrong bag, bar scanning will not catch the error
• Incorporate the 2018-2019 Targeted Medication Safety Best Practices for Hospitals
The ISMP tasked itself to identify, inspire, and mobilize widespread, national adoption of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications. To this end they compiled the 2016-2017 and 2018-2019 Targeted Medication Safety Best Practices for Hospitals. ISMP strongly advises facilities to implement both if they have not (ISMP, 2018-2019).
No one wants to harm a patient in anyway. It is essential that we look at our practices to ensure that we are not taking shortcuts when performing the risk reduction strategies our facility has in place. If you are taking shortcuts, then it is time to review and revise the strategies and develop a new process. Protect your patient, yourself, your facility by practicing safe medication administration.
How does a healthcare provider meet this standard of care? That is the question fueling the concept that independent double checks are one of nursing’s “sacred cows” (ISMP, 2013; Hewitt, Chreim, Forster, 2016). A “sacred cow” is a practice that is grounded in tradition rather than science and is considered ineffective and unnecessary (Miller, Hayes, & Carey, 2015). With this in mind, a brief search of the literature returns a plethora of high-quality, evidence based research findings of the benefits of the independent double-check, quickly dispelling the notion of it being a “sacred cow”. The value of the independent double-check has been repeatedly reaffirmed in research studies.
Institute for Safe Medication Practices (ISMP). (2018-20190). ISMP Targeted Medication Safety Best Practices for Hospitals. Retrieved from: https://www.ismp.org/sites/default/files/attachments/2019-01/TMSBP-for-Hospitalsv2.pdf
Institute for Safe Medication Practices (ISMP). (2018). High-alert medications in acute care settings. Retrieved from: https://www.ismp.org/recommendations/high-alert-medications-acute-list
Diabetesincontrol.com (13). Updating your high-medication list
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