Nurse speaking with patient about medication

Hospital Strategies to Reduce Harm from High-Alert Medications

For over a decade, the Institute for Safe Medication Practices (ISMP) has classified some of the most powerful drugs prescribed to hospital patients as "high-alert medications" because of their increased risk to cause serious harm if used or dosed incorrectly.

"Most hospitals have been working to improve the safety of high-alert medications for a long time," said Frank Federico, RPh, Director of the Institute for Healthcare Improvement, in a 2007 IHI online article, High-Alert Medications Require Heightened Vigilance. "But when you ask if they still need help with it, there is a resounding ‘yes.’"

Of the ISMP’s 19 high-alert medications categories, four are receiving the most attention due to one of the IHI’s 5 Million Lives Campaign initiatives, Prevent Harm from High-Alert Medications. The medication categories include anticoagulants (heparin), narcotic and opiates, insulin and sedatives (neuromuscular blocking agents).

About eight medications within these four categories account for 31 percent of all medication errors, according to the ISMP. Errors resulting from high-alert medications are not necessarily more common, but their consequences are more severe.

"The campaign’s goal is to achieve a 50 percent reduction in harm related to high-alert medications," stated Federico in his report in the September 2007 issue of the Joint Commission Journal on Quality and Healthcare Safety. "Adverse drug events can be reduced significantly by implementing recognized safety measures, such as standardizing and simplifying core medication processes in known high-risk areas, redesigning delivery systems using proven human factors principles, partnering with patients, and creating safety cultures that minimize blame and maximize communication."

Additionally, the ISMP suggests that high-alert medications should be packaged, stored, prescribed and administered differently than other drugs. Hospitals should use "forcing functions," whether they are "hard" (technology) or "soft" (work processes) that eliminate or reduce the possibility of errors.

Baxter Healthcare Corporation has introduced enhanced drug labeling for heparin, in response to recent accidental overdoses of the drug in infants at Methodist Hospital in Indianapolis and Cedars-Sinai Medical Center in Los Angeles. The package label now has a much larger font size, a different color combination and a large, red, cautionary tear-off label as additional safeguards to assist clinicians in the correct identification of critical medications.

In a Nursing 2007 article, author Hedy Cohen RN, BSN, MS writes that technology, such as computerized physician order entry systems, bar coding, smart IV pumps and specially designed medical equipment, like oral syringes that don’t fit into luer-lock intravenous tubing connections or ports, are examples of hard forcing functions. Automated dispensing cabinets and bedside medication-administration systems and scanners are other types of technological mistake-proof strategies that hospitals are using.

One human performance-related tool that hospitals can use to improve their safety practices is a self-checking, decision-making technique called STAR: Stop, Think, Act, Review, used to solve problems and resolve conflicts.

Hospitals are also adhering to Six Sigma methodology, a disciplined, data-driven approach that aims to reduce, if not eliminate, defects or variances in any type of processes in order to improve quality. Many are using the IHI Global Trigger Tool, which is part of the IHI’s How-to-Guide Prevent Harm from High-Alert Medications, to measure and identify adverse drug events and the level of harm caused by the medications.

In its hospital accreditation standards, The Joint Commission requires that hospitals have programs in place to reduce high-alert medication errors but leaves it up to each institution to determine how this should be accomplished.

Adopting a culture of safety and remaining mindful about safety are two areas that the ISMP believes healthcare organizations can improve upon. Hospitals should not be afraid to report risks, errors and near misses related to high-alert medications so that they, as well as others, can learn from their mistakes and willingly make changes to improve patient safety. Mindfulness, rather than complacency, about patient safety should be at the forefront of every hospital staff member’s thoughts and actions.

For detailed information on specific strategies:

Federico F, Preventing harm from high-alert medications. Jt Comm J Qual Patient Saf. 2007 Sept;33(9):537-42.

Cohen H. Reduce the risks of high-alert drugs. Nursing 2007. Sept 2007;37(9):49-55. Available online at

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