High-Alert Medications
Describe the quality of high-alert medications?
What are those with a heightened risk of causing significant harm when used in error
Purpose 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?
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)?
Number of hazardous drug groups
What is 4?
Group 1: Cytotoxic hazardous (carcinogenic)
Group 2: Non-cytotoxic hazardous drugs (other toxic effects)
Group 3: Non-cytotoxic hazardous drugs (pose a developmental or reproductive risk)
Group 4: Biohazardous drugs (pose infectious risk)
Pain must be assessed
- on admission to nursing unit (within 15 minutes)
- for a positive pain screening during We Round
- pre and post analgesic and/or pain management intervention
- at ordered intervals by prescriber and PRN
Number of high-alert medication categories at NH
What is 12?
Timing of pump setting IDC
- 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...
When:
- handling a Group 1 cytotoxic hazardous drug
- handling the human waste of a patient who has received a Group 1 cytotoxic hazardous drug in the last 7 days (regardless of 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
What are:
- Continuous Ambulatory Delivery Device (CADD)
- Epidural
- Intrathecal
- Patient Controlled Analgesia (PCA)
IDC minimum requirements
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)
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
Hazardous Drug Personal Protective Equipment (PPE) resouce
What is PPE: Precautions for Handling, Preparation, Administration on Hazardous Medications SourceNet page
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)?
3 examples of medications requiring IDC
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 (no additional precautions are required for laundry)
- 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
Pain assessment tool for patients unable to self report
What is the Pain Assessment in Advanced Dementia (PAINAD)
Strategy to differentiate look-alike sound-alike medications
What is TALLman lettering (i.e. HYDROmorphone)?
Steps to complete 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
4) Both Nurses co-sign the medication administration
What to do with unused NCDTS
- Waste within a reasonable time frame after dispensing from the ADC
- Do not "hold" for future 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
3 ways nurses provide pain management
- regularly screen and assess for pain using an evidence-based tool
- document pain
- complete reassessment and ongoing assessment of pain
- anticipate and prevent procedural pain