MEDICATION MANUAL Policy & Procedure

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1 MEDICATION MANUAL Policy & Procedure TITLE: High Alert Medication NUMBER: MM Effective Date: September 13, 2013 Page 1 of 6 Applies To: Holders of Medication Manual This policy is applicable to staff in all patient care areas. Individual care teams may have specific policies and protocols that extend beyond limitations set by this policy. POLICY 1. For patient safety, a list of high alert medications is to be available for all healthcare providers involved in the prescribing, dispensing, and administration of these medications. 2. High alert medications are to be safely stored, handled and administered. 3. Capital Health (CH) identifies specific high alert medications as requiring an Independent Double Check. (See Procedure Section High Risk Medications Requiring an Independent Double Check; refer to the Independent Double Check policy (MM ) for further information. Note: It is the accountability of the individual Healthcare Provider to seek an independent double check for additional high alert medications as appropriate (e.g. medications which the HCP is unfamiliar, those given infrequently, etc.) 4. High-alert medications include: 4.1. Insulin, all subcutaneous and Infusions 4.2. Antithrombotics- warfarin, IV heparin, enoxaparin, dalteparin, fondaparinux, argatroban, alteplase, tenecteplase, danaparoid, dabigatran, bivalirudin, eptifibatide, rivaroxaban, tinzaparin, tirofiban, abciximab Concentrated electrolytes, including: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and

2 High Alert Medications MM Page 2 of Hypertonic saline (greater than 0.9%), Potassium chloride inj. (equal to or greater than 2 mmol/ml), Potassium phosphate inj. (vials) Magnesium sulfate inj. (vials - greater than 20%), and Sodium Phosphate inj. (vials) Exception - Exception Dialysate solution 4.4. All chemotherapy doses (Refer to MM Administration of Chemotherapy) 4.5. Narcotics/Opioids Note: For pediatric patients all injectable narcotics/opioids (all dosages/ strengths) require an independent double check. In general, includes patients age 16 and younger. Given that medications are titrated by weight, clinical assessment is required to determine the need for performing an independent double check (I.e.: some younger teenagers are the size of adults) The following high potency injectable narcotics/opioids: Hydromorphone injection with a concentration greater than 2 mg/ml prior to reconstitution Morphine injection with a concentration greater than 10 mg/ml prior to reconstitution Continuous IV narcotics/opioids infusions when administered: outside the Critical Care environment (ICUs, PACU, Operating Rooms and Emergency Departments) via epidural, CADD, PCAs, and syringe drivers (all areas) 4.6. Intravenous vasoactive agents - EPINEPHRine, NORepinephrine, DOPamine, PhenylEPHrine, Isoproterenol, DOBUTamine, vasopressin, esmolol, labetolol, metoprolol, propranolol, nitroglycerine 4.7. IV inotropic medications- digoxin, milrinone 4.8. IV antiarrhythmics- lidocaine, amiodarone 4.9. Neuromuscular blocking agents, - cisatracurium, rocuronium, pancuronium, succinylcholine

3 High Alert Medications MM Page 3 of Anesthetic Agents propofol and ketamine Formulary look-alike/sound-alike medications 5. All pharmacy employees preparing chemotherapy are to have chemotherapy preparation validation. 6. To administer cancer chemotherapy, the Registered Nurse (RN) must successfully complete an approved Post-Entry Level Certification (PELC) program. DEFINITIONS High-Alert Medications: Independent Double Check of a High Alert Medication: Medications that bear a heightened risk of causing significant patient harm when used in error (as defined by the Institute for Safe Medication Practices). The procedure in which two health care providers separately check a high alert medication - alone and apart from each other - then compare results before administering it to the patient. High Potency Narcotics/Opioids: PROCEDURE Narcotic/Opioid products with a strength/potency beyond what is usually required for a single patient dose and which carry a high potential to cause harm. These products are more commonly used to prepare infusions or for bulk compounding of preparations within pharmacy. (Refer to Policy statement 4.5) 1. As per MM Medication Orders, accept verbal or telephone medication orders for high alert medications only when the authorized prescriber is unable to attend to the patient and write the order, and a delay in ordering the medication would compromise patient safety and care. Exception: Orders for chemotherapeutic agents will always be written and signed by an authorized prescriber. 2. Pharmacy provides commercially packaged or pharmacy prepared pre-mixed solutions of high-alert medications when available. 3. Limit the number of concentrations and/or volume options available for all high alert medications on patient areas (MM Wardstock - Inpatient Units and Clinics) 4. For all high alert medications administered as intravenous or epidural infusions, administer in standardized concentrations for adult patients when possible If a concentration other than the standardized concentration is ordered, identify it as such.

4 High Alert Medications MM Page 4 of 6 5. Clearly label all pre-mixed epidural solutions For Epidural Infusion Only and store separately from all intravenous solutions. Note: Labels are issued from Pharmacy. 6. Store insulin (refrigerated) and heparin (room temperature) segregated within their own storage areas. 7. Care and Handling of High Alert Medication Continuous Infusions 7.1. When a patient is transferred between units, the HCP accepting the patient checks all continuous infusions of High Alert Medications (Transfer of Health Information Between Facilities/Transfer of Accountability (unit to unit and shift to shift) CH Clearly label high alert parenteral infusion bags as High Alert Note: Labels may be ordered from Materiel Management (see related documents for order number) ADDITIONAL SAFEGUARDS FOR SPECIFIC HIGH RISK MEDICATIONS THAT REQUIRE AN INDEPENDENT DOUBLE CHECK PRIOR TO ADMINISTRATION (REFER TO MM ) 8. Insulin 8.1. Store Insulin in the refrigerator in segregated bins. Identify the storage bin with a High Alert warning auxiliary sticker. Exception: Patient specific labeled supplies of insulin can be stored at the bedside. 9. Concentrated Electrolytes Note: For Potassium Chloride infusion, please refer to Policy MM : Potassium Chloride for Intravenous Infusion Do not keep concentrated electrolytes in patient care areas except as follows: Hypertonic saline - sodium chloride 3% available in limited supplies as segregated stock Neurosurgery/Neuro-IMCU and Medical/Surgical/Neuro- ICU. 10. High Potency Narcotics/Opioids Pharmacy: Does not dispense high potency narcotics/opioids as routine narcotic ward stock, with the exception of Designated Palliative Care units and

5 High Alert Medications MM Page 5 of 6 areas with the additional safeguards of an automated dispensing cabinet (i.e. Pyxis Medstations) Dispenses high potency narcotics/opioids on a patient specific basis in all other areas Prior to dispensing, labels all high potency narcotics/opioids with a High Alert warning auxiliary sticker Staff members (pharmacy technicians or nurses) on clinical care areas return all high potency narcotics/opioids to the pharmacy upon discontinuation of the medication or discharge of the patient. 11. Cancer Chemotherapy Agents Pharmacy employees: Prepare all chemotherapy doses within the pharmacy department Do an independent double check when performing computer order entry of chemotherapeutic agents in the pharmacy information system Dispenses chemotherapy for intrathecal use and chemotherapy for intravenous use through separate operational procedures. ADDITIONAL SAFEGUARDS FOR SPECIFIC HIGH ALERT MEDICATIONS THAT DO NOT REQUIRE AN INDEPENDENT DOUBLE CHECK 12. Heparin Note: Heparin will be available pre-mixed in one standard concentration Document when a dose/infusion rate changes and the rationale for the changes Store Heparin at room temperature 13. Intravenous Vasoactive Agents Authorized prescriber orders specify a dose range and titration parameters. 14. Neuromuscular Blocking Agents Authorized prescriber orders specify a dose range, titration parameters, and Critical Care protocol ( train of four ) monitoring for continuous infusions. Pharmacy provides neuromuscular blocking agents as ward stock only to critical care areas, emergency departments, and Anaesthesia/ORs Store neuromuscular blocking agents, in designated areas, in separately labeled containers, which are clearly identified.

6 High Alert Medications MM Page 6 of Prior to dispensing, pharmacy labels all neuromuscular blocking agents, Warning: Paralyzing Agent, Causes Respiratory Arrest For use in intubated patients only, 15. Formulary Look-Alike/Sound-Alike (LASA) Medications Pharmacy: Uses Tall-Man lettering for identification of LASA meds on unit-dose packaging and in automated dispensing cabinets (i.e. Pyxis Medstations) Posts CDHA TALLman letter medication list on-line on the Pharmacy intranet page Segregates LASA products in the automated dispensing cabinets (i.e. Pyxis Medstations). REFERENCES ISMP List of High Alert Medications (2012). Institute for Safe Medication Practices IWK Health Centre (2010). High Alert Medications Independent Double Check Medication Management Policy / Procedure Joseph Brant Memorial Hospital Pharmacy Department Manual Policy / Procedure High Alert Medication 2010 RELATED DOCUMENTS Policies CC Neuromuscular Blockade Agents and Train of Four Monitoring MM Medication Orders MM Independent Double Check (pending) MM Potassium Chloride for Intravenous Infusion MM Ward stock - Inpatient Units and Clinics MM Methadone Administration - Offender Health Services MM Methadone, Prescribing & Administering to In-Patients MM Administration of Cancer Chemotherapy A- 002 Ordering and Administration of Intrathecal Chemotherapy Other Labels for High Alert Medication Infusions (Product Code 8353); (Materiels Management orders from Pharmasystems) ***

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