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Children's Hospital Medical Center

Online Policies

II-118 High Alert Medications

Original Date: 2/12/2003 Last Review Date: 1/14/2004

Purpose
To define a safe and efficient way of ordering, dispensing and administering medications that require
special precautions.

Process
The following is a list of specific medications and medication classes that are presently on the CCHMC
formulary which have been classified as high alert due to special requirements defined in the table
below. The medications listed under each class heading are examples only and not intended to represent
a complete list. NOTE SPECIFIC ROUTE WHEN APPLICABLE. Non-formulary medications which
fall under these same medication classes must follow the same precautions.

All of the medications in these classes will have dose range checkers and absolute blocks in computer
order entry and BOLDED medication names on the pharmacy printed labels sent on patient's
medications.

Drug/Drug Classes CCHMC Physician Registered Pharmacist

Policy **
Nurse (RN)

ANESTHETICS P&T Only credentialed Registered nurses may Dosage

(GENERAL) (IV) V-114 faculty members and administer these calculations
their designees from the medications in will be checked
z etomidate Divisions of Critical sedative, hypnotic or by a pharmacist
Care Medicine, analgesic doses. any time they
z ketamine Emergency Medicine, appear on the
z methohexital, Neonatology, or the Verify the drug and physician’s
thiopental and other Department of dose to be administered order form.
barbiturates Anesthesia and with the physician's
z midazolam and credentialed faculty order/MAR*.
other attending in the Cardiac
benzodiazapines Intensive Care Unit and
z propofol cardiac catheterization
z sufentanil and other lab or their
designee may order
opioids
intravenous
medications (narcotics,
ketamine,
pentobarbital, etc.) in
doses intended to
provide anesthesia.

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ANTIARRHYTHMICS Clinical mg/kg dose of drug Verify the drug and Dosage
Practices used in calculation dose to be administered calculations
I-122 must be included on with the physician’s will be checked
z adenosine
written order sheet. order/MAR*. by a pharmacist
z amiodarone any time they
z bretylium For continuous If not prepared by appear on the
z digoxin (see infusions concentration Pharmacy, then physician’s
separate category) (ie. mcg/mL), dose (ie. independent order form
z flecainide mcg/kg/min) and rate calculation by two RNs
z lidocaine (IV) (ie. mL/hour) must be and with double check Oral
(continuous infusion included on the written of amount of antiarrhythmics
restricted to Critical order sheet. medication drawn up.‡ will be
Care areas) dispensed as
z procainamide P&T Physician must be at For continuous unit dose
z sotalol (restricted to IV-102 the bedside for infusions patient IV
use by Cardiology; initiation of IV push infusion cards should Verbal orders
initiation and dose antiarrhythmics be used with all only in an
changes are antiarrhythmics. emergency
restricted to PICU, Verbal orders only in Dosage calculations
CICU, and an emergency approved on these
telemetry. cards are to be
independently
z Verapamil
calculated by two RNs
and initialed.

Verbal orders only in

an emergency

ANTICONVULSANTS mg/kg dose of drug Verify the drug and Dosage

(IV) used in calculation dose to be administered calculations
must be included on with the physician's will be checked
z diazepam written order sheet. order/MAR*. by a pharmacist
any time they
z fosphenytoin appear on the
Serum levels should be If not prepared by
z lorazepam utilized to adjust dosing pharmacy, then physician’s
z midazolam for fosphenytoin, independent order form
z pentobarbital pentobarbital, calculation by two RNs
(Schedule II-also phenobarbital, and double check of Verbal orders
see controlled phenytoin and valporic amount of medication only in an
substances section acid drawn up.‡ emergency
of this policy)
z phenobarbital Verbal orders only in Verbal orders only in
z phenytoin an emergency an emergency
z thiopental
z valproic acid and
derivatives

ANTIHYPERTENSIVES/ P&T mg/kg dose of drug Verify the drug and Dosage
VASODILATORS (IV) IV-124 used in calculation dose to be administered calculations
must be included on with the physician's will be checked
z alprostadil written order sheet. order/MAR*. by a pharmacist
any time they
z clonidine appear on the
Clinical For continuous If not prepared by
z diazoxide infusions concentration pharmacy, then physician’s
Practices order form.
z enalaprilat (ie. mcg/mL), dose (ie. independent
I-122
z esmolol mcg/kg/min) and rate calculation by two RNs
z hydralazine (ie. mL/hour) must be and double check of Verbal orders

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z labetalol included on written amount of medication only in an

z nicardipine order sheet. drawn up.‡ emergency
z nitroglycerin
Verbal orders only in For continuous
z nitroprusside
an emergency infusions patient IV
z phentolmine infusion cards should
z propranolol be used with all
z trimethaphan antihypertensives/
vasodilators. Dosage
calculations approved
on these cards are to be
independently
calculated by two RNs
and initialed.

Verbal orders only in

an emergency

ANTIFUNGALS Check renal function Verify the drug and Dosage

tests and ensure normal dose to be administered calculations
z amphotericin B (IV) electrolytes prior to with the physician's will be checked
ordering. order/MAR*. by a pharmacist
z amphotericin B any time they
liposome (IV) appear on the
physician’s
order form.

BRONCHODILATORS Ensure normal Verify the drug and Dosage

(IV) electrolytes prior to dose to be administered calculations
ordering. with the physician's will be checked
order/MAR*. by a pharmacist
z isoproterenol
For continuous any time they
z terbutaline appear on the
infusions the For continuous
z theophylline concentration (ie. infusions patient IV physician’s
mg/mL), dose infusion cards should order form.
(mg/kg/hour), and rate be used with all
(ie. mg/mL) must be bronchodilators.
included on the written Dosage calculations
order sheet. approved on these
cards are to be
independently
calculated by two RNs
and initialed.

CHEMOTHERAPEUTIC P&T mg/kg dose of drug Verify the drug to be Dosage

AGENTS IV-117 used in calculation administered with the calculations
must be included on physician's will be checked
z asparaginase written order sheet. order/MAR*. by a pharmacist
any time they
z bleomycin appear on the
Clinical An attending physician For all chemotherapy
z busulfan or designee trained in orders, the nurse who physician's
Practices order form.
z carmustine chemotherapy protocols signs off the order
I-122
z chlorambucil must generate an must check patient
z cisplatin inactive order which is weight and dose For inpatient IV
z cyclophosphamide signed and activated by calculation for chemotherapy,
a second attending accuracy. the calculations
z cytarabine P&T physician within 24 will be recorded
z dacarbazine II-101 hours of medication on a
The RN administering

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z dactinomycin administration. the IV medication must chemotherapy

z daunorubicin have successfully worksheet.
No verbal orders completed an Mathematical
z doxorubicin educational program calculations,
z etoposide for chemotherapy including
z fluorouracil drugs. volumes and
z hydroxyurea products,
z ifosfamide New IV access needle required for
or angiocath must be compounding
z lomustine must be verified
used when
z mechlorethamine by a second
administering a
z melphalan vesicant. person. A
z mercaptopurine pharmacist
z methotrexate must perform
Hematology /Oncology the final
z plicamycin nurse practitioner may verification.
z procarbazine administer intrathecal
z thioguanine chemotherapy.
No verbal
z thiotepa orders
No verbal orders
z vinblastine
z vincristine

CONTROLLED Clinical mg/kg or mcg/kg dose Verify the drug and Dosage
SUBSTANCES (Injectable Practices of drug used in dose to be administered calculations
narcotics, barbiturates) I-122 calculation must be with the physician's will be checked
included on written order/MAR*. by a pharmacist
z butorphanol order sheet. any time they
Independent appear on the
z codeine (Schedule physician's
II) For continuous calculation of dosage
infusions the by two RNs at time order form.
z diazepam concentration (ie. medication is drawn
z fentanyl (Schedule mg/mL), dose (ie. up.‡ Verify the amount Schedule II-
II) mg/kg/hour) and rate of medication that is verbal orders
z hydromorphone (ie. mL/hour) must be drawn up. only in
(Schedule II) included on written emergency
z ketamine order sheet. Specify concentration
z lorazepam of drug in comment
z meperidine Schedule II – verbal section of MAR.
(Schedule II) orders only in an
emergency For continuous
z methadone
(Schedule II) infusions patient IV
z methohexital infusion cards should
be used with all
z midazolam controlled substances.
z morphine (Schedule Dosage calculations
II) approved on these
z pentobarbital cards are to be
(Schedule II) independently
z phenobarbital calculated by two RNs
z sufentanil (Schedule and initialed
II)
z thiopental Exception: IV infusion
cards are not required
for PCA and epidural
pumps.

Schedule II-verbal
orders only in

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emergency

DIGOXIN P&T Specify order in mg Verify the drug and Dosage

IV-102 and micrograms, dose to be administered calculations
volume, and with the physician's will be checked
concentration. order/MAR*. by a pharmacist
any time they
Dosage calculation Dose calculation must appear on the
P&T physician's
II-101 must be included on be double-checked
written order sheet. with RN or LPN with order form.
Pharmacology.
Physician must be at
bedside for IV push. Prior to administration,
Clinical amount drawn up for Verbal orders
Practices IV push and/or PO only in an
I-122 Verbal orders only in
an emergency doses must be double- emergency
checked by two RNs or
a RN and a physician.

Physician must be at
bedside for IV push.

Verbal orders only in

an emergency

HEPARIN Clinical For continuous Verify the drug to be Dosage

(unfractionated) Practices infusions concentration administered with the calculations
I-122 (ie. units/mL), dose (ie. physician’s will be checked
units/kg/hour) and rate order/MAR* by a pharmacist
(mL/hour) must be any time they
included on the written Verbal orders only in appear on the
order sheet. an emergency physician's
order form.
Exception: Low dose For continuous
heparin (less than 4 infusions patient IV For use of stock
units/ml and 5 infusion cards should concentrations
units/kg/hr) used to be used with Heparin. greater than
keep catheters open Dosage calculations 1000 units/mL,
need not include the approved on these mathematical
above. cards are to be calculations
independently required for
PT, PTT and INR calculated by two RNs compounding ;
should be utilized to and initialed volumes used
adjust dosing. in
compounding
Exception: Low dose and products
Verbal orders only in heparin (less than 4 used in
an emergency units/ml and 5 compounding
units/kg/hr) used to must be verified
keep catheters open by a second
need not include the person. A
above. pharmacist
must perform
final
verification.

Verbal orders
only in an

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emergency

IMMUNO- Serum levels should be Verify the drug to be Dosage

SUPRESSANTS utilized to adjust dosing administered with the calculations
for cyclosporine and physician’s will be checked
tacrolimus. order/MAR* by a pharmacist
z azathioprine
any time they
(IV/PO)
IV tacrolimus may only appear on the
z basiliximab (IV) physician's
be ordered by an
z cyclosporine attending physician order form.
(IV/PO) involved with
z mercaptopurine transplantation.
(IV/PO)
z muromonab-CD3
(IV)
z tacrolimus (IV/PO)

INOTROPIC AGENTS Clinical Concentration (ie. Verify the drug to be Dosage

(Continuous Vasoactive Practices mcg/mL), dose (ie. administered with the calculations
Agents) (IV) I-122 mcg/kg/minute) and physician’s will be checked
rate (ie. mL/hour) must order/MAR* by a pharmacist
z dobutamine be included on the any time they
written order sheet. Patient IV infusion appear on the
z dopamine physician's
cards should be used
z epinephrine with all inotropic order form.
Verbal orders only in
z metaraminol an emergency agents. Dosage
z milrinone calculations on these Verbal orders
z norepinephrine cards are to be only in an
z phenylephrine independently emergency
calculated by two RNs
z vasopressin and initialed.

Verbal orders only in

an emergency

INSULIN P&T For continuous Verify the drug to be Dosage

(only regular II-101 infusions concentration administered with the calculations
insulin can be given IV) (ie. units/mL), dose (ie. physician’s will be checked
units/kg/hour) and rate order/MAR* by a pharmacist
(ie. mL/hour) must be any time they
included on the written Two RNs or a RN and appear on the
order sheet. a physician must check physician's
IV dose calculations. order form.
Glucose value should
be monitored to assess For subcutaneous
adequacy of therapy. administration of
insulin, drug
calculations must be
double-checked.
Double-checking
includes verification
that the correct drug
and dosage are given
by inspecting the vial
and checking math
calculations. The
second person for
double-checking may

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include RN, LPN with

pharmacology and/or
the diabetic educated
patient or parent.

For continuous
infusions of insulin
patient IV infusion
cards should be used.
Dosage calculations
approved on these
cards are to be
independently
calculated by two RNs
and initialed.

Glucose value should

be monitored to assess
adequacy of therapy.

IRON RELATED Due to the risk of Verify the drug to be Dosage

hypotension, the administered with the calculations
z deferoxamine patient’s blood pressure physician’s order/MAR will be checked
needs to be monitored. by a pharmacist
z ferric gluconate (IV) any time they
Due to the risk of
z iron dextran hypotension, the appear on the
(neonatal use only) patient’s blood physician's
pressure needs to be order form.
monitored.

NEUROMUSCULAR In patient care areas, Verify the drug and Dosage

BLOCKERS only credentialed dose to be administered calculations
faculty members and with the physician's will be checked
their designee from the order/MAR*. by a pharmacist
z atracurium
Divisions of Critical any time they
z mivacurium Care Medicine, appear on the
Independent
z pancuronium Emergency Medicine, calculation of dosage physician's
z rocuronium Neonatology or the by two RNs at time order form.
z succinylcholine Department of medication is drawn
z tubocurarine Anesthesia and up.‡ Verify the amount
attending/designee in of medication that is
z vecuronium the Cardiac Intensive drawn up.
Care Unit and the
Cardiac Catherization
Lab may order these For continuous
medications. infusions of
neuromuscular
blockers patient IV
For continuous infusion cards should
infusions concentration be used. Dosage
(ie. mg/mL), dose (ie. calculations approved
mg/kg/hour) and rate on these cards are to be
(ie. mL/hour) must be independently
included on the written calculated by two RNs
order sheet. and initialed.

Specify concentration
of drug in comment

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section of MAR.

POTASSIUM (IV) P&T Potassium level must Verify the drug and Dosage
IV-121 be checked prior to dose to be administered calculations
ordering. with the physician's will be checked
order/MAR*. by a pharmacist
Concentrations greater any time they
than 0.3 mEq/kg IV appear on the
requires attending co- physician's
signature on the written order form.
order.

MISCELLANEOUS Contact the For use as systemic Verify the drug and Dosage
Divisions of fibrinolytic therapy for dose to be administered calculations
Alteplase (for continuous Critical vascular thrombosis. with the physician’s will be checked
infusion) Care or order/MAR* by a pharmacist
Hematology any time they
for ordering appear on the
guidelines physician’s
order form.

doxapram mg/Kg dose of drug Verify the drug and Dosage

(respiratory and CNS used in calculation dose to be administered calculations
stimulant) must be included on with the physician’s will be checked
written order sheet. order/MAR* by a pharmacist
any time they
appear on the
physician’s
order form.

interferon (multiple Confirm appropriate Confirm appropriate Confirm

products) interferon product. interferon product. appropriate
interferon
product.

neostigmine (IV) mg/Kg dose of drug Verify the drug and Dosage
used in calculation dose to be administered calculations
must be included on with the physician’s will be checked
written order sheet. order/MAR* by a pharmacist
any time they
appear on the
physician’s
order form.

Pentamidine (IV) Requires Cannot be Dosage

cardiopulmonary administered as an calculations
monitoring and pulse outpatient. will be checked
oximetery during by a pharmacist
infusion. Verify the drug and any time they
dose to be administered appear on the
with the physician's physician's
order/MAR* order form.

pralidoxime mg/Kg dose of drug Verify the drug and Dosage

used in calculation dose to be administered calculations
must be included on with the physician’s will be checked
written order sheet. order/MAR* by a pharmacist
any time they

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appear on the
physician’s
order form.

* The electronic MAR will suffice for verification with physician order when available

** Mathematical calculation double checks are not necessary if the order is placed in ICIS.

‡ Independent RN dosage check is not required during a code situation, provided that the RN
checks the dose against standardized weight-based dosing cards from the code cart.

Implementation
This policy will be reviewed at least once a year or more often if deemed necessary. An updated version
of this policy will be provided in Policy Viewer.

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Disclaimer: This policy is no longer valid after 9/27/2004 10:35:04 AM.

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