Effective Date: 1/04

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1 North Shore-Long Island Jewish Health System Long Island Jewish Medical Center POLICY TITLE: Prepared by: System Pharmacy & Therapeutics Committee Effective 1/04 PATIENT CARE MANUAL Last Reviewed / Revised: 1/04, 10/07, 11/08, 5/10, 4/12, 9/13, 7/14 Total Pages: 10 GENERAL STATEMENT OF PURPOSE: High-alert medications are those drugs that bear a heightened risk of causing significant patient harm when used in error. Though mistakes may or may not be more common with these agents, the consequences of such an error carry the potential for devastating outcomes. The Joint Commission (TJC) Medication Management (MM) standards require institutions to identify, in writing, its high-alert medications, develop a process for managing high-alert medications, and implement its process. POLICY: Identify and review a list of high-alert drugs specific to the North Shore LIJ Health System. This list will be used to ensure that safeguards are put in place to prevent medication errors and protect the patient. SCOPE: This policy applies to all members of the North Shore LIJ Health System work force but not limited to employees, business associates, medical staff, volunteers, students, physician office staff, and other persons performing work for or at North Shore LIJ Health System. PROCEDURE / GUIDELINES: The System P&T Committee has agreed to designate the following drug pairs as North Shore LIJ Health System high-alert medications (see Appendix I). Requests to add or remove agents from this list will be directed to the System P&T Committee. The ultimate decision to modify this policy shall lie with the System P&T Committee membership. Due to differing medication management processes at each Health System site and the implementation of various technology solutions, the exact strategies (i.e. processes) for managing high-alert medications shall be determined by local P&T Committees (see Appendix II). Recommended strategies may include, but are not limited to: Standardizing the ordering, storage, preparation, and administration of these products Improving access to information about these drugs Limiting access to high-alert medications Using auxiliary labels and automated alerts Employing redundancies such as automated or independent double-checks Document: Reviewed/Revised July 2014 Page 1/10

2 LIJMC HIGH-ALERT MEDICATION MANAGEMENT STRATEGIES: Storage: Auxiliary labels and other visual cues (e.g., red bins) are used to identify high-alert agents whenever possible Transcription / Ordering: High Alert Medications approved by the System P&T Committee will be configured in Enterprise Sunrise. All adult orderables for these agents will be flagged as High Alert to alert all health care providers. Preparing / Dispensing: Concentrations and/or doses are standardized whenever possible Administration: Smart pumps are utilized for continuous IV infusions whenever possible Administration guidelines are standardized (e.g., IV admixture guide) Monitoring: Continuous tracking, trending and analysis of suspected drug reactions and medication errors are performed. Assessment of the effectiveness of the implemented high-alert medication strategies in the promotion of patient safety via the prevention of medication errors is ongoing through both the Medication Safety and the Pharmacy and Therapeutics Committees. Reporting of suspected drug reactions and medication errors to the Department of Quality Management and the Performance Improvement Coordinating Group is maintained on a monthly basis, with appropriate action taken as necessary. REFERENCES: The Joint Commission s Hospital Accreditation Standards Medication Management ISMP s List of Document: Reviewed/Revised July 2014 Page 2/10

3 Reviewed / Approved by: LIJMC Pharmacy & Therapeutics Committee 07/09/14 Reviewed / Approved by: LIJMC Medical Board 07/22/14 SIGNATURES: Richard Schwarz, Medical Director (LIJ) Margaret Murphy, Chief Nursing Officer (LIJ) Joseph Simpson, Chair, Pharmacy & Therapeutics Committee (LIJ) Dana Rucco, Director of Pharmacy Services (LIJ) Blaine Greenwald, Acting Medical Director (ZHH) Mary Beth McManus, Associate Executive Director I, PCS (ZHH) Neil Kremen, Chair, Pharmacy & Therapeutics Committee (ZHH) Anthony Longo, Director of Pharmacy Services (ZHH) Document: Reviewed/Revised July 2014 Page 3/10

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