Accreditation 2023 - Medication Use

High Alert Medications by Hope Weisenberg 

High-alert medications are medications that bear a heightened risk of causing significant patient harm when they are used in error. Errors are not necessarily more common with these medications, but the consequences of an error can be devastating. High-alert medications include:

• Anticoagulants/thrombolytic agents
• Adrenergic agents
• Chemotherapeutic agents
• Concentrated electrolytes
• Insulin
• Narcotics (opioids)
• Neuromuscular blocking agents
• Sedation agents

Ensuring a safe and coordinated use of high-alert medications is also a Required Organizational Practice of Accreditation Canada.

Pembroke Regional Hospital (PRH) promotes safety best practices when dispensing and administering high-alert medications through the implementation of safeguards that reduce the possibility of harm. The Medical Advisory Committee (MAC) approves/maintains a list of High-Alert Medications and it is reviewed at least annually by the Chief of Pharmacy. Any significant changes to the list are reviewed by the Medication Management Committee, as well as any other applicable committee deemed appropriate. Clinicians share this responsibility which includes reporting incidents through the RIMS system.

Part of the Strategies for the safe use of high-alert medications at PRH include:

• Standardizing medication concentrations and volume options
• Using pre-mixed (commercially available) solutions
• Using programmable pumps with dosing limits and automated alerts
• Identifying high-alert products when they are received and issued by Pharmacy
• Using visible warning and auxiliary labels
• Using patient-specific labelling for unusual concentrations
• Limiting access to high-alert medications in patient care areas and auditing to assess for items that should be removed
• Standardizing the ordering, storage, preparation, administration, and dispensing of high-alert medications
• Providing training about high-alert medications
• Employing redundancies, such as independent double checks

PRH also has a standardized process for an Independent Double Check of select high-alert medications, where a second practitioner conducts verification without any prior knowledge of the preparatory steps or calculations performed by the first practitioner. Click here for the ‘Q-Tip’. This process is then documented on the Medication Administration Record (MAR), or hospital approved flow sheet.  

PRH maintains a list of high-alert medications and associated safeguards. "High-Alert Medication and Independent Double Check" policy document available on the intranet under Policy Medical and the "High Alert Medication List" can also be found on the intranet under IV Manual “Appendix High Alert Medications”.