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High Alert Medications

Education for Staff

Medication Management Safety Team

May 2015
High Alert Medications (HAMs)
Learning Objectives:
 Define and identify what High Alert
Medications (HAMs) are.
 Be aware and understand the risks, errors
and adverse events associated with HAMs.
 Be familiar with the key messages in the
policies and procedures and the educational
resources on CompassionNet
 Be familiar with HAM safeguards
Education for HAMs

It is the responsibility of the healthcare professional to

maintain current knowledge by accessing resources
including, but not limited to, the following:
1. High Alert Medication Policy Suite on CompassionNet

2. Resources which identify high alert medications, such as the

Provincial Parenteral Monographs and other Covenant Health
approved resources;
3. Medication safety notices (e.g.. ISMP Nurse AdvisERR)
distributed by the Medication Management Safety Team
4. High Alert Medication list (See Appendix A of the High Alert
Medication Policy)
5. High Alert Medications Education Module for Pharmacy
Services (Storage and Labelling Resource
What are High Alert Medications?
 Medications that that bear a heightened risk
of causing significant patient harm when
they are used in error (ISMP).

 When used in error the consequences to

patients are devastating .
Why are HAMs a Medication Safety
 They are more likely than other medications to be
associated with harm (ISMP 2014)

 When used improperly will produce more serious

harm to patients/residents than other medications

 The harm from HAMs not only increases patient

suffering, but also increases resources and
costs associated with care of these patients
Case Review #1
Atracurium,a neuromuscular blocking agent, (a high alert
medication) was given to seven newborn babies instead of
hepatitis B vaccine
Five babies recovered, one baby had permanent injury and
one baby died.
atracurium was not a wardstock item on the NICU, however
it was placed in fridge by an anesthetist for convenience.
Pharmacy did not notice the atracurium in fridge.
HAM Categories
The following HAM categories have been associated with errors
within the Organization as well as globally ( AHS, etc):

1) IV Adrenergic agonists
(e.g. epinephrine, ephedrine, dopamine, dobutamine, etc.)

2) Anesthetic agents

3) Antithrombotic agents (oral and IV)

4) Chemotheraphy medications
HAM Categories (con’t)
The following HAM categories have been associated with errors within the
Organization as well as globally ( AHS, etc):

5) Epidural and Intrathecal Medications

6) Insulin

7) Liposomal Drugs

8) Narcotics

9) Neuromuscular Blocking Agents

Examples of Canada’s Top Ten Adverse Events
Medication # of Adverse Events % of Adverse Events

Insulin 145 9.8%

H morphine 133 8.9%

A hydroMORPHone 115 7.7%
M heparin 74 5%
fentaNYL 55 3.75%
warfarin 51 3.4%
metoprolol 37 2.55%
Furosemide not a HAM 32 2.2%
oxyCODONE 21 1.4%
H *9 out of the 10 medications are high alert medications
M 01Jan2000 – 30June2008 ISMP
What Can We Do?
 Develop practices to reduce the harm from
HAM (development of Policies and Procedures)

 Create awareness with HAM related errors to

promote practice change

 Develop multiple risk reduction strategies for

the management of high alert medications and
take appropriate action once a HAM is identified.
Principles of HAM Safety
 Reduce or eliminate the possibility of error
• Differentiate medications using typographic strategies (Tallman)
• Labelling of HAM done by pharmacy
• Standardize concentrations

 Make errors visible

• Independent double checks
• Barcode technology
• “Expect to Check”

 Minimize the consequences of HAM errors (to mitigate

the impact)
• Reduce availability of selected HAM on units.
• Monitor patients effects to identify errors.
• Promote patient education by informing patient of HAM side effects.
HAM Policy & Procedures
• Covenant Health has one main High Alert Medication (HAM) Policy &

• Purpose of the Policy is to promote patient safety and prevent harm

related to HAMs.

• To address the Accreditation Canada ROPs for safeguarding HAMS

• To enhance utilization and reduce errors, 3 separate polices were added to

the HAM Policy as addendums for the managing of specific HAM categories
 Management of HAM - Heparins

 Management of HAM - Narcotics

 Management of HAM - Concentrated Electrolytes

NOTE: Required Organizational Practices Exceptions may be granted*

HAMs Policy & Procedures: Key
 HAMs management require a standard approach
• HAMs must be clearly identified
• All staff should be familiar with HAM polices & procedures

 Labelling and Storage

• Labelling and storage is described in the Covenant Health
Storage and Labelling Guidelines for Pharmacy
• Pharmacy is responsible for labelling
• Nursing staff to notify pharmacy if HAM labelling is missing
HAM Policy & Procedures: Key
 Wardstock Restrictions
• HAM policies clearly outline wardstock restrictions as
defined by Accreditation Canada
• Be Familiar with what Required Organizational Practice
Exception is for HAMs

 HAM education modules

• Guideline for Clinical Nurse Educators
• HAM overview module
• Covenant Health HAM list poster
• Fact Sheets

 HAM audits
• HAM audits are to be done annually.
• Audit tools are provided by the Medication Management
Safety Team
Risk Reduction Strategies
 Standardizing storage and labelling of
• Poor storage and unclear labelling of medications can lead to
selection errors

 Pharmacy will be responsible for ALL labeling of

• Nursing will not label, remove labels or have drugs in places
(kits or trays) without prior consultation with pharmacy

 Limit storage areas for HAMs

• Numerous HAM storage areas can increase medication errors

 Maintenance is a shared responsibility between

pharmacy and clinical areas
Comparison of
Unlabeled and Labeled Storage


Unlabeled Medication Storage Labeled Medication Trays

High Alert Icon and Auxiliary
High Alert Icon

Pyxis Storage
HAM Auxiliary label: ICON
ICON Concentrated Electrolytes
Additional Risk Reduction Strategies

 Tall Man lettering

 Independent double check
• Covenant Health corporate policy for independent
double check VII-A-50 is currently in development.

NOTE: Please talk to your clinical leads if you have

Key Safety Principles Description Examples
Limit Access or Use Restrict meds, require special No access to pharmacy by
training, conditions for a part non-pharmacy staff
of med process e.g Careful selection drugs,
prescribing concentrations
No concentrated electrolytes
Forcing Functions Prevention Oral syringes do not affix to IV
SMART pumps =hard limits
Default settings for epidural
Standardize Uniform models of care PPCOs
Prohibited abbreviations
Standardize insulin sliding
Simplify Reduce steps in med process Commercially prepared
Dosing charts instead of
Limit concentrations
Unit dose packages
Key Safety Principles Description Examples

Patient Monitoring Access effects of meds through Vital sign, lab tests,
constant feed-back loop. neurological signs for patients
having HAM
Monitor for effects of HAM
Chart Audits (e.g. insulin
induced hypoglycemia,
heparin/warfarin induced
bleeding, use of narcan for over

Improve access to information Active means of providing staff Current drug database
and patients with necessary Quick reference tables
information exactly when Increased visibility pharmacists
required, during critical tasks Medical librarian
Computer order entry

Reminders Addditional alerts/ warnings to Auxiliary labels, Label IV lines,

make information highly visible Checklists for complex
during medication process processes, Special monitoring
in PPCOs
Alarms and visual reminders
Key Safety Principles Description Examples

Externalize of Centralize Transfer to external site who Commercial products

Error prone processes can maintain environment Special service e.g TPN
Cardioplegic solutions
Redundancies Implement duplicate steps IDC,
,more than qualified staff for Bar coding
specialized processes SMART pump alarms,
Review of handwritten orders
with nurse before leaving unit
Differentiate Items Modify packages and labels of Auxiliary labels, e.g paralyzing
meds for visual identification. agent , epidural
For look—like or sound-a-like colour,
circle MARs
Tallman lettering
Look A-like And Sound A-like:
With and Without Tall Man Lettering

hydralazine hydroxyzine hydrALAZINE hydrOXYzine

cerebyx celebrex ceREBYX ceLEBRex

vinblastine vincristine vinBLASTine vinCRIStine

chlorpropamide chlorpromazine chlorproPAMIDE chlorproMAZINE

glipizide glyburide glipiZIDE glyBURIDE

daunorubicin doxorubicin DAUNOrubicin DOXOrubicin

Some Major Practice Changes

 Change in labelling and storage containers

• When you see the HAM label take extra care.

 Availability of certain HAM is restricted

 Independent double check (IDC) must be
performed on HAMs.
 Common goal is improve patient safety and prevent
harm from the use of HAM.
Case Review #2 :
 An epidural infusion with HYDROmorphone 0.01 mg/ mL and
BUPivicaine 0.125% was running at 10 mL/hr. The patient was
also receiving Lactated Ringers solution. The nurse mistakenly
changed the rate to 100 mL/hr on the epidural pump instead of
the Lactated Ringers pump. The patient received 90 mL of the
epidural infusion in one hour. The patient made a complete
 HAM Error Reduction Strategies:
• To alert staff the auxiliary label “For Epidural USE” is applied
on all epidural infusion products and storage containers. A
HAM icon label is applied to all storage containers.
• Tall Man lettering is used for HYDROmorphone and
Case Review #3 :
 Two critically ill patients in a Calgary Intensive Care Unit were
mistakenly given potassium chloride solution (KCL) while receiving
dialysis. An elderly woman and a middle-aged man, both died as a
result of a mix-up in the preparation of the solution by Pharmacy.
Potassium chloride was used instead of sodium chloride in a batch
of dialysis. The bottles of medication were similar in size, shape and
labeling. The error went undetected through a 4 check process.

 HAM Error Reduction Strategy:

• A HAM icon label is on all concentrated electrolyte storage
containers. Caution “potassium” and “sodium” auxiliary labels
are applied to storage containers.
• A change of supplier for sodium chloride was initiated to
change the look alike products available.
• Concentrated electrolytes are restricted in patient care areas
ROP exception approvals only.
Case Review # 4
A healthy 16-year-old girl died during labor after an
epidural analgesic (presumably containing
bupivacaine) was inadvertently infused
 Five minutes after the start of the infusion the
patient was noted to experience "seizures, clenched
jaw and gasping respirations" (WISCTV, 2006).
Efforts to resuscitate the patient were unsuccessful
CompassionNet Resources
3. Name of the policy

Policies and

High Alert
Institute Of Medicine’s (IOM)
Quality Chasm Series
HAM Policy Suite: Contents & Links
Covenant Health High Alert Medications
Covenant Health Managing of High Alert Medications:
High Potency Narcotics Policy
Covenant Health Managing of High Alert Medications:
Heparin Policy
Covenant Health Managing of High Alert Medications:
Concentrated Electrolyte Policy
1. Alberta Health Services High Alert Medication Policy Education power point Retrieved November 4, 2014, from

2. Choo,J., Hutchinson,A.,& Bucknall,T.(2010) Nurses’ role in medication safety. Journal of Nursing Management,18,853-861

3. Cuirong,X., Guohong,L., Nanyuan,Y., & Yanyan,l.(2012). An intervention to improve medication management : A before and
after study. Journal of Nursing Management, 22,286-294.

4. Disclosure of Adverse Events, Close Calls &Hazards Policy No. III-40 Retrieved November 6 , 2014 from

5. High Alert Medication Policy VII-A-30 Retrieved November 7,2014 from

6. Medication Administration VII-A-50. Retrieved November 6, 2014 from


7. MoreOb Module 1, Chapter : Communication Retrieved ,November 7, 2014 from

8. Introduction to medication safety World Health Organization WHO:

9. Institute for Safe Medication Practices Canada, Home Page Retrieved November 9, from

10. ISMP Canada Safety Bulletin Volume 14 Issue 4 April 16 2014 Alert: Wrong Route Incidents with Epinephrine Retrieved
November 1 2014

11. CARNA:>Resources>Document List >Medication Guidelines

12. CARNA Jan 2014 : Medication Guidelines

References (con’t)
1. Institute for Medication Safety.( 2014). Medication Safety Intensive. Binder . Unpublished manuscript. Available to
those who attend the program.

2. Pennsylvania Patient Safety Advisory PA PSRS Patient Saf Advis (2006 Dec;3) Let’s Stop the Bleeding: Preventing
Errors with Heparin Therapy Retrieved November 1, 2014,

3. Presentation Summary : QSEN (Quality and Safety Education in Nursing) Partnership in Education and Practice
Jane H. Barnsteiner, PhD, RN, FAAN Professor, University of Pennsylvania Retrieved November ,24,2014 from

4. Power Point 8.33MB Australia Commission on Safety and Quality


5. Responding to Adverse Events, Close Calls and Hazards Policy No. III-45 Retrieved November,7,2014 from

6. Ross Baker, G., Norton,P.G., Flintoft,V., Blais,R., Brown.A., Cox.J., et al.(2004).The Canadian Adverse Events Study:
incidence of adverse events among hospital patients in Canada.Canadian Medical Association Journal/170,1678-

7. Smetzer, Judy BSN,FISMP Medication Safety Intensive Conference –Culture of Patient Safety: Embracing a Just Culture
Institute for Safe Medication Practices Retrieved Dec 16, 2014

8. Western Australian Department of Health Medication Safety Retrieved November 12,2014 from

9. World Health Organization. Improving Medication Safety. WHO Patient Safety Curriculum Guide: Multiprofessional
Edition, 2011. Retrieved November 12,2014 from

10.Canadian Patient Safety Institute www.patientsafetyinstit

High Alert Medications

Picture by Spengben Haiku Deck