Medication errors are one of the most common causes of preventable patient harm in a healthcare organization. The Patient Safety Network (PSN) of the Agency for Healthcare Research and Quality (AHRQ), defines a medication error as “an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication.” Some medications have a higher risk of causing serious harm to patients (including death) when used in error than others. These are referred to as high-alert medications.
In 1995/1996, the Institute for Safe Medication Practices (ISMP) conducted a study to discover the drugs and situations that were most likely to cause patient harm. The study found that most medication errors that resulted in serious injury or caused the death of a patient, were due to a specific list of medications. The ISMP maintains a list of potential high-alert medications which is updated as more information on medication errors become available. Some of the medications included on the list are:
- opiates and narcotics
- insulin, IV and subcutaneous
- injectable potassium chloride concentrate
- anticoagulants such as warfarin and low molecular weight heparin
Despite their preventable nature, medication errors continue to occur. The ISMP has developed and made available, a tool that healthcare practitioners can use to conduct a self-assessment of their systems and practices relating to some high-alert medications. The ISMP Medication Safety Assessment for High-Alert Medications Tool is targeted to hospitals, long-term care facilities, and outpatient facilities. According to the ISMP, the tool is designed to:
- Heighten healthcare providers’ awareness of critical safe medication systems and practices associated with high-alert medications
- Assist healthcare providers with identifying and prioritizing opportunities for reducing patient harm when prescribing, preparing, dispensing, and administering high-alert medications
- Create a baseline of national efforts to enhance safety when prescribing, preparing, dispensing, and administering high-alert medications
- Determine the challenges healthcare providers face in keeping patients safe during high-alert medication use
The ISMP Medication Safety Assessment for High-Alert Medications Tool focusses on 11 targeted categories of high-alert medications such as insulin, opioids, and neuromuscular blocking agents. There are also general assessment items that are applicable to all high-alert medications.
Healthcare organizations are encouraged to:
- Use the ISMP Medication Safety Assessment for High-Alert Medications Tool to assess your practices for all the categories of high-alert medications used in your facility
- Submit the findings to ISMP anonymously online (you will receive weighted scores so you can compare your findings to demographically similar organizations)
Below are links to some useful resources to guide you in creating your policies and procedures relating to safe medication practices:
- CDC’s Guideline for Prescribing Opioids for Chronic Pain
- ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults
- ISMP Safe Practice Guidelines for Adult IV Push Medications
Medication errors can be deadly and are highly preventable. Use established guidelines as the ISMP tool to assess your practices, and to benefit from best practices that you can use to help in preventing these errors.