High Alert Medication Self Study Module

Transcription

1 High Alert Medication Self Study Module 2011 Module Prepared by: Regional Patient Care Services NCAL Pharmacy Nursing Steering Committee

2 Introduction: While many medication errors may not cause grave harm to patients, high alert medications are those drugs which are involved in a higher percentage of medication incidences and/or sentinel and significant events, or that carry an increased risk for error, abuse, injury or other adverse outcomes. The High Alert Medication List Policy and Procedure is known as HAMP. Pg. 2

3 Module Purpose: The purpose of this self-learning module is to provide the professional nurse with current information regarding the standardization of high alert medication handling practices and the safe administration of medications. Pg. 3

4 Objectives: 1. Describe the process for an independent double check when giving High Alert Medications. 2. Define time out when giving specified High Alert Medications. 3. Describe the location of the list of the KP High Alert Medications Pg. 4

5 Directions: 1. Read the attached module and review the addendums. 2. Complete the practice questions within the module. 3. Complete the post test, with your signed attestation sheet, and give it to the administrator of the module. 4. You must pass the test with 100% correct responses. Pg. 5

6 High Alert Medication Policy Medication practice changes have been implemented to increase the safety of our patients. Kaiser Permanente (KP) High Alert medication standards apply to inpatient and outpatient care, physicians, nurses, pharmacists everyone who handles high alert medications. Medical Center Policy: High Alert Medication List Policy and Procedure governs this program. Pg. 6

7 High Alert Medication Policy KP high alert medication safe practices require: 1. Use of a specified high alert medication list 2. Independent double check at patient s bedside for all HAMP medications 3. Documentation in the electronic medical record (KP HealthConnect) at the time of administration Pg. 7

8 High Alert Medication Policy Components: Standardization of labeling: IV infusions must include required alerts, warnings and labels Standardized doses and concentrations Recommendations for use of Smart pump technology if given as an IV infusion Time Out for vinca alkaloids and all medications administered by the intrathecal route Pg. 8

9 High Alert Medication Policy Question: The High Alert Medication Policy includes: A. Independent double check at bedside B. High alert medication list C. Standardized concentration D. Recommendations for use of Smart pump technology for IV infusions. E. All of the above Pg. 9

10 High Alert Medication Policy Answer: E - All of the above. More options include: Time out for vinca alkaloids Documentation in the electronic medical record at time of administration. Pg. 10

11 Independent Double Check: A procedure in which 2 authorized, qualified practitioners will separately check each component of the work process. For example, one person calculating a medication dose for a specific patient and a second individual independently performing the same calculation (not just verifying the results). The pharmacy will be consulted in the event that agreement cannot be reached. Pg. 11

12 Independent Double Check: Question: During the independent double check, if two health practitioners do not agree on the calculated dose, they should take the average between their two numbers. True or False? Pg. 12

13 Independent Double Check: Answer: False A pharmacist should be consulted in the event that agreement cannot be reached. Pg. 13

14 Independent Double Check: The independent Double check is performed at the bedside and includes the Five Rights of Medication Administration. Right Patient Right Time, Date and Frequency of Administration Right Dose Right Route Right Drug Pg. 14

15 Right Patient includes: Identification using 2 patient identifiers: name, medical record number, or birth date (per local policy). Pg. 15

16 Right Time, Date and Frequency of Administration Includes the following: Is the dosing frequency/timing appropriate for this patient? Also remember to include: Have the appropriate monitoring tests and guidelines been ordered? Pg. 16

17 Right Dose includes the following: Is the prescribed dose appropriate for this patient? Mathematic calculations using appropriate factors and formula (eg: mg/ml, mg/kg, etc.) Right rate of infusion: (including calculations if applicable) Pg. 17

18 Right Route includes the following: Is the route of administration safe and proper for this patient? Also include: Check labeling, IV tubing connection, and site of line insertion IV Pump setting and safety software activation if applicable Is the infusion line connected to the right port? Pg. 18

19 Right Drug Includes the following: Do the drug indications match the patient s diagnosis or condition? Was the drug checked against Medication Administration Record (MAR), physician order and/or PYXIS tape? Is this the right formulation of the drug? Is this the right drug strength or concentration Pg. 19

20 Independent Double Check Resources A training video done by the RN Quality Liaisons demonstrates the correct method for doing an independent double check It can be found at on the Nursing pathways Website: el/highalertmed/index.html Pg. 20

21 Independent Double Check Considerations: Question: Name 3 steps that must be completed (as appropriate), along with the 5 rights, during an independent double check? Pg. 21

22 Independent Double Check Answers: Were two patient identifiers used to identify the patient? Does the drug indication match the patient s diagnosis or condition? Was the drug checked against the MAR and physician order or PYXIS tape? Is this the right formulation of the drug? Is this the right strength of the drug? Is the prescribed dose appropriate for this patient? Is the dosing frequency/timing appropriate for this patient? Is the route of administration safe and proper for this patient? Is the rate of administration appropriate for this patient and drug? Is the infusion line connected to the right port? Has the labeling, tubing and site of insertion been checked? Is the safety software activated on the IV pump? Have the appropriate monitoring tests and guidelines been ordered? Pg. 22

23 Time Out: A TIME OUT is required for: 1) Vinca alkaloids 2) All medications administered by the intrathecal route and must be conducted immediately before starting administration/ procedure, in the location where the procedure will be done. Pg. 23

24 Time Out: A TIME OUT must involve the entire care/procedure team, use active communication, be documented using the KP Universal Protocol documentation forms and must at least include: 1. Verification of Correct patient identity (use two patient identifiers). 2. Correct side and site (verify appropriateness of drug and if giving medication IV, verify patency of IV line). Pg. 24

25 Time Out (continued): 3. Agreement on the procedure and/or medication to be done/given, with the patient (discuss with the patient the medication and administration procedure) 4. Correct patient position 5. Availability of correct implants and any special equipment or special requirements (e.g.: infusion devices) 6. Follow the organization s processes for reconciling differences in staff responses during the Universal Protocol for time out. Pg. 25

26 Time Out: Question: The high alert medication Time Out involves the entire care/procedure team except the physician? True or False? Pg. 26

27 Time Out: Answer: False! It includes the physician and the patient. The team also must use active communication which is documented using KP Universal Protocol documentation systems. Pg. 27

28 High Alert Medications Include: A. Vinca Alkaloids: VinCRIStine, VinBLAStine, Vinorelbine B. Continuous Heparin, Lepirudin and Agatroban Infusions C. Insulin : Continuous Infusions and U500 Insulin Injection D. Neuromuscular Blocking Agents Pg. 28

29 High Alert Medications Include: E. IV, Intraperitoneal and Intrathecal Cytotoxic Chemotherapy Agents F. Concentrated Electrolytes (>0.9% NaCL, and > 0.4 meq/ml Potassium Injection) G. Magnesium Sulfate Infusions (40mg/ml) with total IV bag volume greater than 100 ml H. Alteplase (t-pa Activase) IV Infusions Pg. 29

30 High Alert Medications Include: I. Tenecteplase (TNKase ) IV Injections J. Epinephrine, Norepinephrine, Phenylephrine and Isoproterenol Infusions K. Opiate/Narcotic Infusions including PCA therapy L. Medications Administered via the Intrathecal Route Pg. 30

31 High Alert Medications Include: M. Medications administered via the Epidural Route N. Medications administered to Neonates in the Neonatal Intensive Care Unit (NICU) and Special Care Nursery (SCN) Pg. 31

32 High Alert Medications Include: O. Medications administered to Pediatric patients: (Age 0 13) Adult High Alert drug list and the additional medications listed below: All doses of IV medications in critical care areas including ED All medications used for procedural sedation except when administered by anesthesia provider; Digoxin (all routes) Chloral Hydrate (all routes) Pg. 32

33 High Alert Meds All High Alert Meds & Routes General Requirements Require an independent double check at the bedside by two appropriate persons and documentation on medical record at administration, at bag change and at transfers/handoffs. In addition, the process of performing an independent double check includes checking labeling, IV tubing connection and site of line insertion along with other factors as appropriate. Includes all inpatient and outpatient settings All physicians, nurses and others who administer medications will have medication administration training and will comply with the regional policy and procedure Red High Alert stickers are utilized Emergency situations (i.e., Codes) are excluded A current admission weight should be obtained for all patients and fluctuations in body weight assessed when needed to ensure accurate weight-based dosing calculation. 33

34 High Alert Meds Requirements Heparin, Argatroban and Lepirudin Infusions Insulin Infusions Concentrated Electrolytes Do not use u in orders Store vials separately from insulin The regional standard for Heparin Infusion is 25,000 units/250 ml (100 Units/mL). Smart pump with safety software activated shall be used for infusions Double check at rate change required No overrides if stored and dispensed from Pyxis Do not use u in orders Infusions compounded in Pharmacy Standard concentration Smart pump with safety software activated shall be used for infusions Sodium infusions greater than 0.9% Potassium infusions greater than or equal to 0.4 meq/ml Storage restricted to pharmacy Use pre-mixed products when available 34

35 High Alert Meds U-500 Insulin Injection Requirements All orders for U-500 insulin require endocrinology approval The abbreviation u will not be accepted for insulin orders U-500 insulin will be stored only in the pharmacy department A soft stop Best Practice Alert will appear in KP HealthConnect requiring the prescriber and pharmacist to confirm the need for the U-500 insulin concentration. Total doses of U-500 insulin will be expressed in terms of both units and volume All doses of U-500 insulin will be prepared by pharmacy in 1 ml tuberculin (TB) syringes with patient-specific labeling The term Conc (concentrated) will appear in the U-500 label Administration Instructions in KP HealthConnect shall include a caution regarding syringe measurements, units and volume, use of a TB syringe and a High Alert Medication warning Independent double checks in the pharmacy and at the patient s bedside immediately prior to administration 35

36 High Alert Meds Narcotic/Opiate Infusions, including PCA Requirements Use PCA pumps for controlled drug infusions for patient safety and security Standard concentrations used throughout the region Morphine 1mg/mL Meperidine 10mg/mL Hydromorphone 0.2mg/mL Labeling to show non-standard concentration product to differentiate from standard concentration Double check at rate changes required All Intrathecal meds Requires staff follow the Universal Protocol for Time Out All Epidural meds Use standard concentrations for infusions Use infusion pump for patient safety and security Special labeling for containers Where feasible, color-coded or labeled tubing without injection ports shall be used for administering opiate/narcotic epidural infusions. 36

37 High Alert Meds IV, Intraperitoneal and Intrathecal Cytotoxic Chemotherapy Infusions Requirements Independent double check required in pharmacy process Use special packaging and labeling Verbal orders not accepted except for date/time changes or clarifications No dosing by course of treatment Use preprinted orders whenever possible Minimum set of information required for medication orders Use of specialized computer software in pharmacy (e.g., COPS or CAMMALOT) Chemo competent staff for all administration Independent double check includes date and time of administration Vinca Alkaloids VinCRIStine VinBLAStine Vinorelbine Dispensed in mini-bag, rare exception for peds with noncentral line Requires a Time Out Labeled Fatal if given intrathecally. For IV use only. Do not remove covering until moment of injection. 37

38 High Alert Meds Requirements Neuromuscular Blocking Agents Restrict floor stock to ED, OR, PACU, Critical Care and LDRP Store separately with special labeling to differentiate from other meds Use identification techniques (e.g., labels, etc) shrink wrap not required Verify intubation status prior to administration Clinical Data Category alert in PYXIS Magnesium Sulfate Infusion Standard concentrations 40 mg/ml Bag volume greater than 100 ml is High Alert Use pre-mixed products when available Standard concentrations 40 mg/ml 38

39 High Alert Meds Alteplase (Activase, t-pa) Infusions Tenecteplase (TNKase ) Epinephrine, Norepinephrine, Phenylephrine, Isoproterenol Infusions Requirements Infusions compounded in pharmacy; emergency exceptions will be tracked. Alteplase will be supplied by the pharmacy in two patient-specific doses as determined by patient weight; overfill must be discarded Special labeling requirements Clinical Data Category alert in Pyxis to differentiate from tenecteplase (TNKase) Whenever stored in an automated dispensing cabinet (Pyxis), an onscreen alert ( Clinical Data Category ) shall be used to differentiate the product from alteplase (t-pa) and minimize the possibility of a substitution error Clinical Data Category alert in Pyxis to differentiate from tenecteplase (TNKase) Standard infusion concentrations Epinephrine: 8 micrograms/ml Norepinephrine 16 micrograms/ml Phenylephrine: 160 micrograms/ml Isoproterenol 4 micrograms/ml Independent double check at rate changes not required 39

40 High Alert Meds Requirements All Neonates in NICU and Special Care Nursery (SCN) All medications are High Alert Pediatrics (0-13 yr) All adult High Alert medications All doses of IV medications in Critical Care areas, including ED All medications used for procedural sedation, except if administered by an anesthesia provider Digoxin (all routes) Chloral hydrate (all routes) 40

41 High Alert Medications: Question: Who will prepare U500 insulin for subcutaneous administration and what type of syringe will be used? Pg. 41

42 High Alert Medications Include: Answer: Pharmacy will prepare all U500 insulin doses in 1 ml TB syringes with patient specific labeling for nurses to administer. Pg. 42

43 Hand-Off An independent double check is required whenever there is a transfer of responsibility for the care of the patient. This includes change of shift, change of primary assignment, transfer of patients between units or levels of care An independent double check is required for break-relief only if there is an expected bag change, change in drug dose, rate of infusion or pump settings. Pg. 43

44 Hand-Off Question: If I go on a break, the person relieving me only has to do a Hand Off when there is an expected bag change, change in drug dosage, rate of infusion, or pump setting. True or False? Pg. 44

45 Hand-Off Answer: True! The Hand Off with an independent double check is required whenever there is a transfer of responsibility for the care of the patient and there is an expected bag change, change in drug dose, rate of infusion or pump settings. If no changes are expected, a normal report out is acceptable. Pg. 45

46 What is expected from you.. Follow and adhere to the policy: Your colleagues and support staff will follow your example. Our members safety is worth this extra effort Report errors and near-misses using an Responsible Reporting Form (RRF); reporting will help us continue to find and correct systems issues Pg. 46

47 High Alert Medication Policy Our path to improved patient safety Pg. 47