Managing High Alert Medication
These medications require additional safety precautions because errors involving them are more likely to cause significant patient harm.
What are high-alert medications?
This tool or system helps nurses identify early signs of acute clinical deterioration by monitoring vital signs, clinical assessments, and other indicators before a medical emergency occurs.
What is an Early Warning System (EWS)?
Before administering medications, collecting blood work, or providing any treatment, this minimum number of person-specific identifiers must be used to confirm a client's identity.
What are two-patient identifiers?
This evidence-informed process is the first step used to identify clients who may be at risk for suicide and determines whether further assessment is required.
What is suicide risk screening?
This process is used to briefly identify clients who may be at risk for falls and determines whether a more comprehensive assessment is needed.
What is a falls risk screening?
Name three medications or medication classes that are considered high-alert medications according to the RSP.
What are insulin, anticoagulants (e.g., heparin/warfarin), opioids, concentrated electrolytes (e.g., potassium chloride), chemotherapeutic agents, or neuromuscular-blocking agents? (Any three.)
During your assessment, a patient on the psychiatric unit has an elevated Early Warning Score after vital signs are obtained. According to the RSP, what is your next priority?
What is following the hospital's care escalation procedure by notifying the appropriate healthcare provider/team (CRN/MRP/hospitalist) and documenting your assessment and actions?
Which of the following is not considered an acceptable client identifier: the client's full name, date of birth, room number, hospital identification band, or confirmed photograph?
What is the client's room number?
According to the RSP, after a client screens positive for suicide risk, what are the next two required actions?
What are keeping the client safe and referring them for a timely suicide risk assessment by a competent person (followed by development of an individualized safety plan)?
Name three environmental modifications that organizations should maintain to help prevent falls and reduce injuries.
What are keeping floors clean and dry, installing handrails or grab bars, ensuring adequate lighting, reducing clutter/overcrowding, using non-slip flooring, conducting environmental safety assessments, or providing appropriate mobility aids?
While preparing a subcutaneous insulin dose for a patient with diabetes on the mental health unit, what safety practice does the RSP recommend before administration?
What is performing an independent double check (and using bar-code medication administration where available) to verify the correct patient, medication, dose, route, and time before administering the insulin?
A patient tells you, "I just don't feel right," even though their vital signs are only mildly abnormal. According to the RSP, why should this concern be taken seriously?
What is because clients and their designated support persons can recognize subtle early signs of deterioration, and nurses should partner with them, assess the client, and escalate concerns if indicated?
Two patients named John Smith are admitted to your mental health unit. What should you use to ensure you are providing care to the correct patient before administering medication?
What are at least two person-specific identifiers, such as the patient's full name and date of birth (or medical record number/identification band), while avoiding the use of room number alone?
Name four elements that should be included in an individualized suicide safety plan.
What are reasons for living, personal warning signs, reducing access to lethal means, emergency contacts/designated support person, local crisis service information, culturally safe interventions, safest care setting, or actions to address imminent self-harm or harm to others? (Any four.)
A client screens positive for fall risk on admission. According to the RSP, what is the next required step before determining interventions?
What is conducting a comprehensive fall risk assessment and documenting the findings in the client's health record and individualized care plan?
A patient who received a prescribed opioid for severe pain is now difficult to arouse and has a respiratory rate of 8 breaths/minute. According to the RSP, what should the nurse consider and what actions should be taken?
What is recognizing that the patient's clinical deterioration may be related to a high-alert medication or adverse drug reaction, immediately assessing the patient, withholding further opioid doses as appropriate, escalating care according to organizational procedures, notifying the most responsible provider or emergency response team, closely monitoring the patient, and documenting all findings and interventions?
A patient receiving clozapine becomes increasingly drowsy, diaphoretic, tachycardic, hypotensive, and difficult to arouse. Using the RSP principles, describe the appropriate nursing response.
What is recognizing these as signs of acute clinical deterioration, initiating the care escalation procedure, communicating findings using a structured tool such as SBAR, notifying the physician or CCOT as appropriate, continuing assessment and monitoring, documenting all interventions, and preparing for transfer to a higher level of care if needed?
A familiar long-term psychiatric patient tells you, "You know who I am—you don't need to check my wristband today." According to the RSP, what is the appropriate nursing response?
What is explaining that client identification is required before every episode of care, respectfully confirming at least two approved person-specific identifiers according to organizational policy, and then proceeding with care?
Why are transitions of care considered a high-risk period in suicide prevention, and what does the RSP require during these transitions?
What is because suicide risk can increase during transitions of care, requiring timely and effective communication of all relevant clinical information, including the suicide risk assessment, safety plan, and follow-up recommendations, to ensure continuity of care?
A patient falls without injury while walking independently to the washroom. According to the RSP, what actions should the healthcare team take after ensuring the patient's immediate safety?
What are documenting the event, completing an IRS, communicating the incident to the client and interprofessional team, reassessing fall risk, reviewing and updating the individualized care plan, and implementing additional interventions to reduce future risk?
During a medication room audit, staff discover that a lorazepam vial is stored on the table in the medication room vs in the ADU, and a near miss occurred when it was almost used instead of haloperidol. According to the RSP, what organizational actions should follow?
What are reporting the hazard and near miss through completion of an IRS, securing and appropriately storing the medication, analyzing the event to identify contributing factors, implementing corrective actions (e.g., restricted access, warning labels, workflow changes, education), monitoring compliance through audits, and using the findings to support benchmarking and continuous quality improvement?
Your unit notices several delayed responses to medically deteriorating psychiatric patients over six months. According to the RSP, what organizational quality improvement activities should occur to reduce future delays?
What are measuring compliance with the early warning system and escalation procedures, reviewing safety and harm data, providing targeted staff education, updating procedures as needed, and demonstrating continuous improvement based on outcomes?
During a medication pass, you discover another nurse almost administered medication to the wrong patient because two clients with similar names were sitting together in the dining room. The error was caught before the medication was given. According to the RSP, what actions should follow?
What are confirming the correct client's identity using two approved identifiers, reporting the close call through the organization's client safety reporting and learning system, documenting as required, analyzing contributing factors (such as similar names or workflow issues), implementing improvements to reduce future risk, and sharing lessons learned to support continuous quality improvement?
During an environmental safety review on an inpatient mental health unit, staff identify unsecured ligature risks and a client expresses concerns about their room. According to the RSP, what organizational and team actions should occur?
What are conducting transparent safety checks, addressing identified environmental risks, involving the client or support person in identifying safety concerns, incorporating client-specific safety measures into the individualized safety plan, documenting actions taken, and maintaining a secure environment for all?
Accreditation Canada states that preventing falls requires more than screening and interventions. Name four additional organizational components that support a comprehensive falls prevention program.
What are: