'High-alert' medications and patient safety.

Abstract

This ‘Patient Safety Alert’ is the second in a series of periodic features in the Journal providing important information regarding the occurrence, management and prevention of sentinel events. A ‘sentinel event’ is an unexpected occurrence involving death or serious physical or psychological injury, or the risk of such injury. This risk includes any variation in a care provision process, where recurrence of the variation would carry significant likelihood of a serious adverse outcome. Such events are called ‘sentinel’ because they signal the need for immediate investigation and response. These articles are reprinted here with permission of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are based on articles published by JCAHO in the publication ‘Sentinel Event Alert’ which appears on the JCAHO website at www.jcaho.org. In 1996 JCAHO established a Sentinel Event Policy designed to encourage health care organizations to self-report health care errors. In the ensuing years JCAHO has developed and implemented a procedure for recording, assembling and analyzing the data provided in these reports. Application of this carefully formulated process – termed a ‘root cause analysis’ – for identifying the underlying causes of the performance variation or adverse event provides a means for structured investigation of the occurrence and for improvement of systems to prevent reoccurrence. Data reported to the JCAHO under the Sentinel Event Policy by JCAHO-accredited health care organizations and by outside experts and organizations provide the basis for this series of Alerts. Since the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) began tracking sentinel events in 1995, JCAHO’s Board of Commissioners’ Accreditation Committee has reviewed 89 cases related to medication errors, one of the most common causes of avoidable harm to patients in health care organizations. ‘Medication errors have caused serious problems In an address to this same topic, during the years 1995 and 1996 the Institute for Safe in health care organizations. It makes sense to be aware of risk reduction information and react to it Medication Practices (ISMP) in Huntingdon Valley, PA, USA, conducted a study to before something serious takes place.’ determine the drugs and situations most likely to cause harm to patients. Approximately 161 health care organizations submitted data on serious errors that had taken place during this period. The results of the study showed that a majority of the medication errors resulting in death or serious injury involved a small number of specific medications. The ISMP has termed these medications that have the highest risk of causing injury when misused ‘high-alert medications’ [1]. The top five high-alert medications identified by the ISMP are (i) insulin, (ii) opiates and narcotics, (iii) injectable potassium chloride (or phosphate) concentrate [2], (iv) intravenous anticoagulants (heparin) and (v) sodium chloride solutions above 0.9%. Listed below are some common risk factors associated with the storage and use of these high-alert medications and suggested strategies for increasing patient safety and avoiding harm.