Book Need: Storage, handling, Prescribing and Administration of High Alert Drugs

Introduction:

High-alert are drugs that have a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patient.

High alert medications have a higher risk of causing injury, either as a result of a narrow therapeutic range or due to high incidence of reported.

Methods to reduce error include strategies such as improving access to information about these drugs;

· Limiting access to high-alert medications

· Using Tallman lettering, using auxiliary labels and automated alerts

· Standardizing the ordering, storage, preparation and administration of these products.

· Employing redundancies such as independent double checks.

Purpose

The purpose of this policy is to standardise medication safety practices and to serve as minimum standard for the High-alert medications

In order to maximize the safety of all medication processes associated with these medications, each high alert medication has specific medication safety practices required when they are administered. Not all medication safety practices are required for each high-alert medication.

Scope

This policy applies to all staff involved in the storing, dispensing and administration of High alert medication

Duties and responsibilities

Mechanisms are in place for overall implementation, monitoring and revision of this policy and these policies that respect patient’s rights are in place, accessible and understood by all relevant staff.

The Chief Divisionals involved in the scope of this policy are responsible for ensuring that all Service Managers:

· Disseminate the policy in their area of responsibility

· Implement this policy within their area of responsibility

· Identify and allocate appropriate resources in order to comply with this policy

· Ensure that all staff under their supervision has attended training on an annual basis

· Ensure all staff are informed of this policy

The KUP/Leader is responsible for ensuring that :

· All staff have an access to the information about this policy and the procedure related to the policy

· All members of staff adhere to the principle in this policy

· All staff should be familiar with practices referred to in this policy

Responsibilities of all Healthcare staff:

· Must be familiar with and adhere to this policy

· Promote good practice and challenge poor practice

Responsibilities of medical staff

· Ensure compliance with this policy

Responsibilities of the Drug and theraputic Committee:

· The Drug and theruaputic committee has a responsibility to ensure that this policy will comply with advice and guidance from the health department and international bodies.

· The Drug and theraputic committee will ensure to:

· Develop and implement a policy on Management and use of medications in the organisation

· Review the Policy on the receipt of a change in advice or guidance from the health department and other bodies

· Develop and implement all relevant SOPs that are supporting the policy.

High Alert Medication List

a. Concentrated Electrolytes – IV Potassium and 3% sodium chloride

b. Chemotherapy agents

c. Heparin infusions

d. Insulin – both continuous infusion and subcutaneous does

e. Narcotics – infusions, including epidural and spinal route and fentanyl patches

f. Anticoagulants and thrombolytic agents

g. Neuromuscular blocking agents

h. Inotropic agents (dobutamine, Norepinephrine Ephedrine etc)

i. Oxytocin

j. Look alike sound alike (LASA).

k. All medications administered through the Intrathecal route

Storage and Labelling of High-alert Medication:

1. Labelling

a. High alert medication are label with a HIGH ALERT sticker

b. LASA medication

i. Labelled with a “Look alike Sound alike” sticker

ii. Tallman lettering will be used on the standard label. For example: DOBUTamine and DOPamine.

iii. LASA drugs in the same medication group will not be placed next to each other.

iv. Refer to appendix 1. List of LASA drugs used in the Hospital.

2. Storage in Pharmacy

a. High alert medication – will be stored in drugs cupboard, except for;

i. narcotic medications and IV potassium that will be placed and the double locked cupboard and are registered in the controlled drug book.

ii. Store Insulin in the refrigerator in segregated bins. Identify the storage space with a “High Alert” warning auxiliary sticker

iii. Cytotoxic drugs are to be stored as per manufacturers instruction either within a dedicated area of a refrigerator that is continually monitored for temperature or dedicated area in pharmacy for Cytotoxic drugs with clearly labelled and placed in appropriate containers and not mixed with other drugs

iv. Store neuromuscular blocking agents, in designated areas, in separately labelled containers, which are clearly identified

b. High Alert medication will be place in container and label as above with a HIGH Alert sticker

3. Storage in critical care unit and ward units

a. Storage of high alert medications will be stored in the clean utilities room in a single locked cupboard, except for narcotic medications and IV potassium that will be placed and the double locked cupboard and are registered in the controlled drug book.

b. High Alert medication will be place in a red container and label as above with a HIGH Alert sticker

Dispensing of High-alert medications:

1. Pharmacy will only dispense high alert medications to the ward (non-critical care unit), when ordered by the Physician for a patient

a. These drugs include:

i. Insulin

ii. Heparin

iii. Anticoagulants

iv. IV potassium and 3% sodium chloride

v. Chemotherapy agents

b. Pharmacy will dispense the following high alert drugs as floor stock the wards and units:

i. Narcotics

ii. Oxytocin

2. Pharmacy will not dispense the following medication to the ward (non-critical care unit)

a. Inotropic agents

b. Neuromuscular blocking agents (except for the emergency trolley)

c. Thrombolytic agents (streptokinase).

High-Alert Medication Safety Practices:

1. Independent Double Check:

a. Defined as a check of the factors listed below performed independently by two qualified healthcare practitioners (Doctor/nurse/midwife), against the current medication order, before each high alert medication is administered.

i. These checks must be documented on the Medication administration record/anaesthesia record/IV fluid order chart.

ii. The factors to be verified during the independent double check must include:

• Right patient identification using two identifiers – Patient name and date of birth.

• Right drug (verify against the current Physician order)

• Right dose of drug (verified against the infusion pump) including

o Mathematic calculation using appropriate factors

o Strength or concentration of drug

• Right route of administration

• Time of administration

• For patient with IV pump/ syringe drivers – verify the setting, rate of infusion and line attachment.

2. Time Out

a. Is defined as the period of time immediately before initiating a high-alert medication administration/procedure, when two qualified practitioners verify the factor listed below, at the patient’s side in location where medication/procedure will be performed. The time out must be documented on the medical record at the time of occurrence.

b. The factors to be verified during the Time out must include:

i. Availability of any special equipment or special requirement for administration of the medication (e.g. infusion devices), if applicable. For patient with IV pump/syringe driver – verify the setting and rate of infusion

ii. Correct patient identity – patient name and date of birth

iii. Correct side and site – verify appropriateness and adequacy of IV access

iv. Agreement on the medication administration/procedure to be done with the patient – discuss with patient/family the medication and administration procedure

v. Correct patient position for epidural and intrathecal medication administration.

3. Pharmacy Pause

a. Is defined as checks performed independently by two pharmacists or pharmacist and pharmacy assistance before a specified high-alert medication is dispensed from pharmacy.

i. The factors to be verified during the Pharmacy Pause must include:

· Right patient identification using two identifiers – patient name and date of birth.

· Right drug (verified against original physician order)

4. Hand-off

a. Is defined as an interactive process of passing patient specific information from one caregiver to another for purpose of ensuring the continuity and safety of the patient’s care. Hand-off occurs when the nurse transfer responsibility for the patient for the remainder of the workday – e.g. change of shift. Hand off does not include coverage for breaks or meal periods.

Prescribing:

- Prescriber need to have documented diagnosis, condition or indication for use for each high alert medication ordered.

- The following high-alert medications have their own order form:

· Chemotherapy order form

· Intravenous Insulin form

· Subcutaneous Insulin form

· Intravenous Heparin infusion form

- All other high-alert medications must be documented on the Medications chart or the IV fluid order chart. (refer to prescribing policy)

Administration of High Alerts:

- All Provides that administer high risk medications must performed independent double check (refer to section >>>)

- A second provider with medication administration training should perform and document a third check by initialing the “double-check” of that item prior to medication administration on the MAR.

- Whenever administration of a High Alert Medication continuous intravenous infusion is begun, a second caregiver should verify:

o Right patient, Right medication, Right dose, Right time, Right route

o That the intended infusion is going into the intended channel by physically tracing the line from the solution, through the pump, and to the insertion site; and

o That the infusion pump is programmed at the proper rate, including correct entry of the patient’s weight into the pump.

- Any time a patient is transferred between units, the caregiver transferring the patient and the caregiver accepting the patient should be encouraged to check continuous intravenous infusions of all High Alert Medications at the bedside. The caregiver should check for the right patient, right medication, right rate of infusion, and right concentration of medication versus the written order or MAR.

- All continuous intravenous High Alert Medication infusions should be administered via an IV pump or syringe drive (with drug library or drug dose rate calculator).

- Each infusion line should be labeled with the name of the medication being infused at the distal ends of all tubing and across the door of the correct IV pump channel so that two providers can independently trace the line back to the point of entry for confirmation.

- In emergency situations where safety labeling and handling precautions would delay treatment and negatively impact care delivery, the nurse or physician should first determine that the urgency of a patient’s clinical condition warrants bypassing double-check procedures, then the provider administering the medication should announce all drug therapy to another health-care provider immediately before administration.

- Refer to Administration of Medication Policy

- For Refer to Appendix for safety checks for dispensing and Administration requirement for specific high alert medications.

Training

Training and Educationof all staff expected by the hosital to attend training at induction.

The attendance of staff at induction is monitored by the Training and Education Department.Those staff that do not attend are recalled at a later date.

If absence is repeated, the manager is contacted by Training and Education and attendance is ensured at a later date.

Monitoring

3 monthly audits will be carried out to ensure complicance to the this policy

Laman

Storage, handling, Prescribing and Administration of High Alert Drugs

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