High-Alert Medications and Patient Safety

Drug Common Risk Factors Suggested Strategies

• Establish a check system whereby
Insulin • Lack of dose check systems one nurse prepares the dose and
another nurse reviews it
• Insulin and heparin vials kept in close
• Do not store insulin and heparin near
proximity to each other on a nursing unit,
each other
leading to mix-ups
• Use of "U" as an abbreviation for units (which
• Spell out the word "units" instead of
can be confused with "O," resulting in a tenfold
writing "U"
overdose)
• Build in an independent check
• Incorrect rates being programmed into an
system for infusion pump rates and
infusion pump
concentration settings
• Parenteral narcotics stored in nursing areas as • Limit the opiates and narcotics
Opiates and narcotics
floor stock available in floor stock
• Confusion between hydromorphone and • Educate staff about hydromorphone
morphine and morphine mix-ups
• Implement PCA protocols that
• Patient-controlled analgesia (PCA) errors
include double-checks of the drug,
regarding concentration and rate
pump setting, and dosage
Injectable potassium
• Storing concentrated potassium • Remove potassium
chloride or phosphate
chloride/phosphate outside of the pharmacy chloride/phosphate from floor stock
concentrate
• Move drug preparation off units and
• Mixing potassium chloride/phosphate
use commercially available premixed
extemporaneously
IV solutions
• Standardize and limit drug
• Requests for unusual concentrations
concentrations
Intravenous • Unclear labeling regarding concentration and • Standardize concentrations and use
anticoagulants (heparin) total volume premixed solutions
• Multi-dose containers • Use only single-dose containers
• Separate heparin and insulin and
• Confusion between heparin and insulin due to
remove heparin from the top of
similar measurement units and proximity
medication carts
• Limit access of sodium chloride
Sodium chloride • Storing sodium chloride solutions (above
solutions (above 0.9%) and remove
solutions above 0.9% 0.9%) on nursing units
from nursing units
• Large number of concentrations/formulations • Standardize and limit drug
available concentrations
• Double-check pump rate, drug,
• No double-check system in place
concentration, and line attachments