Patient Safety Update
High Alert Medications
BWH defines high alert medications as any medication that bears a heightened risk of causing patient harm when used in error. Current strategies used to decrease medication errors at BWH include:
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Computerized order entry
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Clinical pharmacist medication order review
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Barcode scanning during dispensing and administration of medications
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Smart Pump infusion technology and standardized drug libraries
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Hospital standardized drug administration guidelines and IV dilution guidelines
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Tall man lettering for look alike, sound alike medications
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High risk medication alerts in OE, pharmacy and medication dispensing cabinets.
The Drug Safety Committee has proposed additional interventions focused on three major categories of high alert medications — insulin, opiates and anticoagulants. Working collaboratively with the Pharmacy Services, and the Diabetes, Pharmacy and Therapeutics subcommittee, the Drug Safety Committee is focused on reducing the misadministration of insulin by converting from insulin vials to insulin devices (pens), reducing the number of formulary insulin agents available for in-house administration, developing an intravenous insulin protocol for ICU patient, and developing order set templates for hypoglycemia and subcutaneous insulin regimens. The order sets can be found under the Sets and Templates function of BICS OE.
In collaboration with the Drug Safety, Post-op Pain Committee, the Pharmacy and Therapeutics Committee and the departments of Pharmacy and Nursing, the hospital has upgraded all patient controlled analgesia (PCA) pumps to smart infusion technology PCA pumps. These new pumps are equipped with dosing guardrails that can intercept key-pad programming errors. The Drug Safety committee also is developing new PCA order sets. The new order sets will be equipped with decision support to identify high risk patients and alert prescribers to appropriate dosing recommendations based on patients’ baseline risk status and indication.
As part of the National Patient Safety Goals for 2008, the Joint Commission requires implementing policies and procedures to improve the safe use of anticoagulants. To meet these goals, the Drug Safety Committee is working on implementing:
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anticoagulant management programs individualized to patient care
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policies and protocols that direct the appropriate initiation and maintenance of anticoagulation therapy
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educational efforts directed to prescribers, staff, patients, and families.