High-Alert Medications
Qualities of high-alert medications
What are medications that bear a heightened risk of causing significant harm when they are used in error?
Purpose and most critical aspect of Independent Double Check (IDC)
What is to enhance patient safety and minimize risk through the prevention of medication errors associated with high-alert medications by maximizing the visibility of the error before it reaches the patient?
Most critical aspect is to maintain independence of the double check?
- Nurse 1 DOES NOT communicate what Nurse 2 should see (this would create bias and reduce visibility of the error)
In routine practice, the healthcare provider (HCP) who administers a NCDTS
Who is the HCP that accessed the NCDTS from the Automated Dispensing Cabinet (ADC)?
Description of the hazardous drug groups
Group 1: Cytotoxic hazardous drugs are carcinogenic
Group 2: Non-cytotoxic hazardous drugs have other toxic effects
Group 3: Non-cytotoxic hazardous drugs the pose a developmental or reproductive risk
Group 4: Biohazardous drugs posed an infectious risk
Frequency that pain must be assessed
- on admission to nursing unit (within 15 minutes)
- for a positive pain screening during We Round
- every 8 hours (acute care inpatients)
- pre and post analgesic and/or pain management intervention
- at ordered intervals by prescriber and PRN
Number of medication categories considered as high-alert at NH
What is 12?
Independent Double Checks of pump settings are required
- Initial pump programming
- Changes in pump programming
- Solution changes (i.e. IV bag change)
- Site changes
- Loss of device (i.e. power change, battery change, device restart)
- Transfer of accountability (change of shift and patient transfers)
NCDTS are dispensed from ADC using override
What is minimized and only used in urgent situations?
Cytotoxic precautions are required...
What is when:
- handling a Group 1 cytotoxic hazardous drug
- handling the human waste (urine, feces, emesis) of a patient who has received a Group 1 cytotoxic hazardous drug in the last 7 days (regardless of administration route)
Definition of a pain goal
What is:
- to have the patient's pain controlled at a level that is acceptable to them
- or through the observable improvement of behavioural pain indicators
High-alert routes of medication administration at NH
What are
- Continuous Ambulatory Delivery Device (CADD)
- Epidural
- Intrathecal
- Patient Controlled Analgesia (PCA)
Minimum requirements Nurse 2 must check during IDC
What are:
- correct patient (using 2 patient identifiers)
- correct drug
- correct strength/concentration
- correct dosage
- correct route
- correct time
- independent drug calculations (if applicable)
- pump settings if applicable (concentration in medication container must match concentration programmed on pump, route of administration, infusion rate), line selection and tracing, PCA settings (if applicable)
Process to resolve a discrepancy in the NCDTS inventory count
What is
- discrepancies are resolved ASAP and at minimum prior to the end of shift in which it was generated
- discrepancy is flagged at the top of the ADC screen
- all doses identified in the discrepancy must be accounted for (not simply adjusting the ADC count to match the physical count)
- ADC will prompt second verifier credentials as witness
Staff responsibilities for Personal Protective Equipment (PPE)
- Refer to PPE: Precautions for Handling, Preparation, Administration on Sourcenet
- Wear appropriate PPE for the activity being performed
- Do not begin handing a hazardous drug until necessary supplies and PPE are obtained
Pain assessment tools used at NH
1) Numeric pain intensity scale
2) Faces of pain
3) Pain Assessment in Advanced Dementia (PAINAD)
4) CPOT
5) FLACC
6) NPASS
Two ways high-alert medications are identified at NH
What are:
- pharmacy applies auxiliary labels to individual high-alert medication
- practitioner action associated with Automated Dispensing Cabinet bin (i.e. prompt when IDC is required)?
Medications requiring IDC (with an example of each as able)
What are:
- High dose injectable narcotics (opioids)
- Concentrated electrolytes
- Warfarin
- PCA/epidural/medications administered via CADD pump or intrathecal routes of administration
- Insulin
- Neuromuscular blocking agents
- Antineoplastic injectable agents
- Heparin/glycoprotein IIIb/IIIa inhibitors/ direct thrombin inhibitors
- Oxytocin
- Medications requiring complex calculations
- Other high-alert medications outlined by program specific policies and procedures (age less than 18 years of age, Walker Family Cancer Centre, Women & Babies)
Process to waste an unused or partial dose of NCDTS
1) Immediately following partial dose administration, nurse who accessed NCDTS from the ADC signs in and selects the 'waste' function
2) Partial/remaining dose of medication is disposed in the appropriate waste container
3) Amount wasted is documented in the ADC with a witness (NH staff only- students are not permitted to act as witness for NCDTS)
Describe the process of cytotoxic precautions
- Dispose of all hazardous medications, medical or body waste in appropriate waste containers (laundry is placed in a disposable linen bag, closed and placed with regular laundry- no additional precautions are required)
- Proactively manage toileting and bodily fluids
- Note use of cytotoxic precautions in the Electronic Health Record and post signage outside of room
- Communicate use of cytotoxic precautions during Handover at all transitions in care
Comprehensive pain assessment tool for patients with mild to severe cognitive impairment
What is the Pain Assessment in Advanced Dementia (PAINAD)
Strategy to differentiate look-alike sound-alike medications
What is TALLman lettering (i.e. HYDROmorphone)?
Describe the process of completing an IDC
1) Nurse 1 identifies a high-risk medication and the need to consult a second nurse to conduct an IDC (may request at any time based on your judgement)
2) Nurse 1 prepares medication independently
3) Nurse 2 performs IDC without any advance knowledge of what findings to expect (may be in the presence or absence of Nurse 1)
4) Both Nurses are required to sign in the electronic Medication Administration Record (eMAR)
How to handle unused NCDTS
- Wastage must occur within a reasonable time frame after dispensing from the ADC
- Unused NCDTS are not "held" or stored for future wastage or use
Process to clean a cytotoxic spill
- Respond immediately to control and minimize further contamination of the environment
- Refer to the NH Spill Management Algorithm
- Utilize a cytotoxic spill kill and clean as directed by the Spill Management Algorithm
Principles of Pain Assessment
- screen for pain using an evidence-based tool
- complete a comprehensive pain assessment if required
- complete reassessment and ongoing assessment of pain
- document pain
- communicate findings of pain assessment
- establish a plan for pain management
- anticipate and prevent procedural pain