High Alert Medication

Self Study Module

2011 Module Prepared by:

Regional Patient Care Services
NCAL Pharmacy Nursing Steering
Committee
 Introduction:

While many medication errors may not cause

grave harm to patients, high alert medications are
those drugs which are involved in a higher
percentage of medication incidences and/or
sentinel and significant events, or that carry an
increased risk for error, abuse, injury or other
adverse outcomes. The High Alert Medication
List Policy and Procedure is known as HAMP.

Updated April 2011 Pg. 2

 Module Purpose:

The purpose of this self-learning module

is to provide the professional nurse with
current information regarding the
standardization of high alert medication
handling practices and the safe
administration of medications.

Updated April 2011 Pg. 3

 Objectives:
1. Describe the process for an independent
double check when giving High Alert
Medications.
2. Define time out when giving specified
High Alert Medications.
3. Describe the location of the list of the KP
High Alert Medications

Updated April 2011 Pg. 4

 Directions:
1. Read the attached module and review
the addendums.

2. Complete the practice questions within

the module.

3. Complete the post test, with your

signed attestation sheet, and give it to
the administrator of the module.

4. You must pass the test with 100%

correct responses.
Updated April 2011 Pg. 5
 High Alert Medication Policy
Medication practice changes have been
implemented to increase the safety of our
patients.
Kaiser Permanente (KP) High Alert medication
standards apply to inpatient and outpatient care,
physicians, nurses, pharmacists everyone who
handles high alert medications.
Medical Center Policy: High Alert Medication List
Policy and Procedure governs this program.

Updated April 2011 Pg. 6

 High Alert Medication Policy

KP high alert medication safe practices require:

1. Use of a specified high alert medication list
2. Independent double check at patients
bedside for all HAMP medications
3. Documentation in the electronic medical
record (KP HealthConnect) at the time of
administration

Updated April 2011 Pg. 7

 High Alert Medication Policy Components:

Standardization of labeling:
IV infusions must include required alerts,
warnings and labels
Standardized doses and concentrations
Recommendations for use of Smart pump
technology if given as an IV infusion
Time Out for vinca alkaloids and all
medications administered by the intrathecal
route

Updated April 2011 Pg. 8

 High Alert Medication Policy

Question:
The High Alert Medication Policy includes:
A. Independent double check at bedside
B. High alert medication list
C. Standardized concentration
D. Recommendations for use of Smart
pump technology for IV infusions.
E. All of the above

Updated April 2011 Pg. 9

 High Alert Medication Policy

Answer:
E - All of the above. More options
include:
Time out for vinca alkaloids
Documentation in the electronic
medical record at time of
administration.

Updated April 2011 Pg. 10

 Independent Double Check:

A procedure in which 2 authorized, qualified

practitioners will separately check each
component of the work process.
For example, one person calculating a
medication dose for a specific patient and a
second individual independently performing the
same calculation (not just verifying the results).
The pharmacy will be consulted in the event
that agreement cannot be reached.

Updated April 2011 Pg. 11

 Independent Double Check:

Question:
During the independent double check, if two
health practitioners do not agree on the
calculated dose, they should take the
average between their two numbers.

True or False?

Updated April 2011 Pg. 12

 Independent Double Check:

Answer:
False
A pharmacist should be consulted in the
event that agreement cannot be reached.

Updated April 2011 Pg. 13

 Independent Double Check:

The independent Double check is performed at the

bedside and includes the Five Rights of Medication
Administration.
Right Patient
Right Time, Date and Frequency of
Administration
Right Dose
Right Route
Right Drug

Updated April 2011 Pg. 14

 Right Patient includes:

Identification using 2 patient

identifiers: name, medical record
number, or birth date (per local
policy).

Updated April 2011 Pg. 15

 Right Time, Date and Frequency of Administration
Includes the following:

Is the dosing frequency/timing

appropriate for this patient?

Also remember to include:

Have the appropriate monitoring tests
and guidelines been ordered?

Updated April 2011 Pg. 16

 Right Dose includes the following:

Is the prescribed dose appropriate for

this patient?
Mathematic calculations using
appropriate factors and formula (eg:
mg/ml, mg/kg, etc.)
Right rate of infusion: (including
calculations if applicable)

Updated April 2011 Pg. 17

 Right Route
includes the following:

Is the route of administration safe and

proper for this patient?
Also include:
Check labeling, IV tubing connection, and
site of line insertion
IV Pump setting and safety software
activation if applicable
Is the infusion line connected to the right
port?
Updated April 2011 Pg. 18
 Right Drug
Includes the following:
Do the drug indications match the
patients diagnosis or condition?
Was the drug checked against
Medication Administration Record
(MAR), physician order and/or PYXIS
tape?
Is this the right formulation of the drug?
Is this the right drug strength or
concentration
Updated April 2011 Pg. 19
 Independent Double Check Resources

A training video done by the RN Quality Liaisons

demonstrates the correct method for doing an
independent double check

It can be found at on the Nursing pathways

Website:

http://kpnet.kp.org/nursing/national/learning/c
el/highalertmed/index.html

Updated April 2011 Pg. 20

 Independent Double Check Considerations:

Question:
Name 3 steps that must be completed
(as appropriate), along with the 5
rights, during an independent double
check?

Updated April 2011 Pg. 21

 Independent Double Check Answers:
Were two patient identifiers used to identify the patient?
Does the drug indication match the patients diagnosis or condition?
Was the drug checked against the MAR and physician order or PYXIS
tape?
Is this the right formulation of the drug?
Is this the right strength of the drug?
Is the prescribed dose appropriate for this patient?
Is the dosing frequency/timing appropriate for this patient?
Is the route of administration safe and proper for this patient?
Is the rate of administration appropriate for this patient and drug?
Is the infusion line connected to the right port?
Has the labeling, tubing and site of insertion been checked?
Is the safety software activated on the IV pump?
Have the appropriate monitoring tests and guidelines been ordered?

Updated April 2011 Pg. 22

 Time Out:

A TIME OUT is required for:

1) Vinca alkaloids
2) All medications administered by the
intrathecal route and must be conducted
immediately before starting administration/
procedure, in the location where the
procedure will be done.

Updated April 2011 Pg. 23

 Time Out:

A TIME OUT must involve the entire

care/procedure team, use active communication,
be documented using the KP Universal Protocol
documentation forms and must at least include:
1. Verification of Correct patient identity (use
two patient identifiers).
2. Correct side and site (verify appropriateness
of drug and if giving medication IV, verify
patency of IV line).

Updated April 2011 Pg. 24

 Time Out (continued):
3. Agreement on the procedure and/or medication to
be done/given, with the patient (discuss with the
patient the medication and administration
procedure)
4. Correct patient position
5. Availability of correct implants and any special
equipment or special requirements (e.g.: infusion
devices)
6. Follow the organizations processes for reconciling
differences in staff responses during the Universal
Protocol for time out.
Updated April 2011 Pg. 25
 Time Out:

Question:
The high alert medication Time Out involves
the entire care/procedure team except the
physician?

True or False?

Updated April 2011 Pg. 26

 Time Out:

Answer:
False!
It includes the physician and the patient. The
team also must use active communication
which is documented using KP Universal
Protocol documentation systems.

Updated April 2011 Pg. 27

 High Alert Medications Include:

A. Vinca Alkaloids: VinCRIStine, VinBLAStine,

Vinorelbine
B. Continuous Heparin, Lepirudin and
Agatroban Infusions
C. Insulin : Continuous Infusions and U500
Insulin Injection
D. Neuromuscular Blocking Agents

Updated April 2011 Pg. 28

 High Alert Medications Include:

E. IV, Intraperitoneal and Intrathecal Cytotoxic

Chemotherapy Agents
F. Concentrated Electrolytes (>0.9% NaCL, and >
0.4 mEq/ml Potassium Injection)
G. Magnesium Sulfate Infusions (40mg/ml) with
total IV bag volume greater than 100 ml
H. Alteplase (t-PA Activase) IV Infusions

Updated April 2011 Pg. 29

 High Alert Medications Include:

I. Tenecteplase (TNKase) IV Injections

J. Epinephrine, Norepinephrine, Phenylephrine
and Isoproterenol Infusions
K. Opiate/Narcotic Infusions including PCA
therapy
L. Medications Administered via the Intrathecal
Route

Updated April 2011 Pg. 30

 High Alert Medications Include:

M. Medications administered via the

Epidural Route
N. Medications administered to Neonates
in the Neonatal Intensive Care Unit
(NICU) and Special Care Nursery (SCN)

Updated April 2011 Pg. 31

 High Alert Medications Include:
O. Medications administered to Pediatric patients:
(Age 0 13)
Adult High Alert drug list and the additional
medications listed below:
All doses of IV medications in critical care areas
including ED
All medications used for procedural sedation
except when administered by anesthesia provider;
Digoxin (all routes)
Chloral Hydrate (all routes)

Updated April 2011 Pg. 32

High Alert Meds General Requirements

All High Alert Meds Require an independent double check at the bedside by
& Routes two appropriate persons and documentation on medical
record at administration, at bag change and at
transfers/handoffs.
In addition, the process of performing an independent
double check includes checking labeling, IV tubing
connection and site of line insertion along with other
factors as appropriate.
Includes all inpatient and outpatient settings
All physicians, nurses and others who administer
medications will have medication administration training
and will comply with the regional policy and procedure
Red High Alert stickers are utilized
Emergency situations (i.e., Codes) are excluded
A current admission weight should be obtained for all
patients and fluctuations in body weight assessed when
needed to ensure accurate weight-based dosing
calculation.

Updated April 2011 33

High Alert Meds Requirements

Heparin, Argatroban Do not use u in orders

and Lepirudin Infusions Store vials separately from insulin
The regional standard for Heparin Infusion is 25,000 units/250
mL (100 Units/mL).
Smart pump with safety software activated shall be used for
infusions
Double check at rate change required
No overrides if stored and dispensed from Pyxis
Insulin Infusions Do not use u in orders
Infusions compounded in Pharmacy
Standard concentration
Smart pump with safety software activated shall be used for
infusions
Concentrated Sodium infusions greater than 0.9%
Electrolytes Potassium infusions greater than or equal to 0.4 mEq/mL
Storage restricted to pharmacy
Use pre-mixed products when available
Updated April 2011 34
High Alert Requirements
Meds
U-500 Insulin All orders for U-500 insulin require endocrinology approval
Injection The abbreviation u will not be accepted for insulin orders
U-500 insulin will be stored only in the pharmacy department
A soft stop Best Practice Alert will appear in KP HealthConnect
requiring the prescriber and pharmacist to confirm the need for the
U-500 insulin concentration.
Total doses of U-500 insulin will be expressed in terms of both
units and volume
All doses of U-500 insulin will be prepared by pharmacy in 1 mL
tuberculin (TB) syringes with patient-specific labeling
The term Conc (concentrated) will appear in the U-500 label
Administration Instructions in KP HealthConnect shall include a
caution regarding syringe measurements, units and volume, use of
a TB syringe and a High Alert Medication warning
Independent double checks in the pharmacy and at the patients
bedside immediately prior to administration

Updated April 2011 35

High Alert Meds Requirements
Narcotic/Opiate Use PCA pumps for controlled drug infusions for patient
Infusions, including PCA safety and security
Standard concentrations used throughout the region
Morphine 1mg/mL
Meperidine 10mg/mL
Hydromorphone 0.2mg/mL
Labeling to show non-standard concentration product to
differentiate from standard concentration
Double check at rate changes required

All Intrathecal meds Requires staff follow the Universal Protocol for Time Out

All Epidural meds Use standard concentrations for infusions

Use infusion pump for patient safety and security
Special labeling for containers
Where feasible, color-coded or labeled tubing without
injection ports shall be used for administering opiate/narcotic
epidural infusions.

Updated April 2011 36

High Alert Meds Requirements
IV, Intraperitoneal and Independent double check required in pharmacy process
Intrathecal Cytotoxic Use special packaging and labeling
Chemotherapy Infusions
Verbal orders not accepted except for date/time changes
or clarifications
No dosing by course of treatment
Use preprinted orders whenever possible
Minimum set of information required for medication orders
Use of specialized computer software in pharmacy (e.g.,
COPS or CAMMALOT)
Chemo competent staff for all administration
Independent double check includes date and time of
administration

Vinca Alkaloids Dispensed in mini-bag, rare exception for peds with non-
VinCRIStine central line
VinBLAStine
Vinorelbine
Requires a Time Out
Labeled Fatal if given intrathecally. For IV use only. Do
not remove covering until moment of injection.

Updated April 2011 37

High Alert Meds Requirements

Neuromuscular Restrict floor stock to ED, OR, PACU, Critical Care and LDRP
Blocking Agents Store separately with special labeling to differentiate from other
meds
Use identification techniques (e.g., labels, etc) shrink wrap not
required
Verify intubation status prior to administration
Clinical Data Category alert in PYXIS

Magnesium Sulfate Standard concentrations 40 mg/mL

Infusion Bag volume greater than 100 mL is High Alert
Use pre-mixed products when available
Standard concentrations 40 mg/mL

Updated April 2011 38

High Alert Meds Requirements
Alteplase Infusions compounded in pharmacy; emergency exceptions will be
(Activase, t-PA) tracked.
Infusions
Alteplase will be supplied by the pharmacy in two patient-specific doses
as determined by patient weight; overfill must be discarded
Special labeling requirements
Clinical Data Category alert in Pyxis to differentiate from tenecteplase
(TNKase)
Tenecteplase Whenever stored in an automated dispensing cabinet (Pyxis), an on-
(TNKase) screen alert (Clinical Data Category) shall be used to differentiate the
product from alteplase (t-PA) and minimize the possibility of a substitution
error
Clinical Data Category alert in Pyxis to differentiate from tenecteplase
(TNKase)
Epinephrine, Standard infusion concentrations
Norepinephrine, Epinephrine: 8 micrograms/mL
Phenylephrine,
Isoproterenol
Norepinephrine 16 micrograms/mL
Infusions Phenylephrine: 160 micrograms/mL
Isoproterenol 4 micrograms/mL
Independent double check at rate changes not required
Updated April 2011 39
High Alert Meds Requirements

All Neonates in NICU All medications are High Alert

and Special Care
Nursery (SCN)

Pediatrics (0-13 yr) All adult High Alert medications

All doses of IV medications in Critical Care areas, including ED
All medications used for procedural sedation, except if
administered by an anesthesia provider
Digoxin (all routes)
Chloral hydrate (all routes)

Updated April 2011 40

 High Alert Medications:

Question:
Who will prepare U500 insulin for
subcutaneous administration and what type
of syringe will be used?

Updated April 2011 Pg. 41

 High Alert Medications Include:

Answer:
Pharmacy will prepare all U500 insulin
doses in 1 ml TB syringes with patient
specific labeling for nurses to administer.

Updated April 2011 Pg. 42

 Hand-Off

An independent double check is required

whenever there is a transfer of responsibility for
the care of the patient.
This includes change of shift, change of primary
assignment, transfer of patients between units or
levels of care
An independent double check is required for
break-relief only if there is an expected bag
change, change in drug dose, rate of infusion or
pump settings.
Updated April 2011 Pg. 43
 Hand-Off
Question:
If I go on a break, the person relieving me
only has to do a Hand Off when there is an
expected bag change, change in drug
dosage, rate of infusion, or pump setting.

True or False?

Updated April 2011 Pg. 44

 Hand-Off
Answer:
True!
The Hand Off with an independent double
check is required whenever there is a transfer
of responsibility for the care of the patient and
there is an expected bag change, change in
drug dose, rate of infusion or pump settings. If
no changes are expected, a normal report out
is acceptable.

Updated April 2011 Pg. 45

 What is expected from you . .

Follow and adhere to the policy:

Your colleagues and support staff will follow
your example.
Our members safety is worth this extra effort

Report errors and near-misses using an

Responsible Reporting Form (RRF); reporting will
help us continue to find and correct systems issues

Updated April 2011 Pg. 46

 High Alert Medication Policy

Our path to improved patient

safety

Updated April 2011 Pg. 47