AMRH/PHARM/P&P/005/Vers.

02
Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

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 AMRH/PHARM/P&P/005/Vers.02
Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Content Table:

Acronyms ……………………………………………………... 3
1 Introduction …………………………………………………... 4
2 Scope ………………………………………………………….. 4
3 Purpose ……………………………………………………….. 4
4 Definition ……………………………………………………... 4-5
5 Policy ………………………………………………………..… 5-6
6 Procedure ……………………………………………………... 6-10
7 Responsibility ……………………………………………….. 10
8 Document History and Version Control …………………..... 11
9 Related Documents …………………………………………... 11
10 References …………………………………………………….. 12
11 Appendices ……………………………………………………. 13-19
Appendix 1. Available Formulations in MoH ……….... 13-15
Appendix 2. High-Alert Medications – Common Risk
Factors ………………………….………………………... 16
Appendix 3. Audit Tool …….…………………………… 17
Appendix 4. Document Request Form …………………. 18
Appendix 5. Document Validation Checklist.………….. 19

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Acronyms:

IV Intravenous

CDC Central Drug Committee

FDA Food and Drug Administration

ISMP Institute for Safe Medication Practices

SOP Standard Operating Procedures

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 AMRH/PHARM/P&P/005/Vers.02
Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Policy and Procedure of High-Alert

Medications

1. Introduction

Medication errors are significant and often preventable healthcare problems. Although many
medication errors may not cause harm to patients, some medications are known to carry a
higher risk of harm than other medications, and errors in the administration of these
medications can have catastrophic clinical outcomes. It is required that to identify certain
high-risk, High Alert Medications be used within the facility and further to develop specific
processes for enhancing patient safety regarding their utilization.

The Pharmacy and Medical Stores services in the Al Masarra Hospital developed this
document to keep up an excellence and secure dealings of High-Alert category of
medications in the institution and to maintain a high quality patient care.

2. Scope
This document is applicable to all Pharmacy professionals/Staff Nurses/Doctors of Al
Masarra Hospital.

3. Purpose
3.1 To establish a guideline to identify and standardize the handling and use of High Alert
Medications in patient-care areas, and to outline the steps necessary in increasing
awareness of these medications to prevent potential errors.
3.1 To provide and maintain a list of medication designated as high alert medications to
ensure safe medication practices and eliminate medication errors that cause harm to
patients.

4. Definitions
4.1 High Alert Medications: are medications that bear a heightened risk of causing
significant patient harm when used in error. Though medication mishaps with high
alert medications may or may not be more common than other drugs, the
consequences following an error

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

with these drugs can be especially serious to the patients. These medications include the
following:
4.1.1 Medications that are involve in a high percentage of errors and/or
sentinelevents, such as Insulin and Heparin etc.
4.1.2 Medication whose names, packaging and labeling, or clinical use, look
alikeand/or sound alike, such as Amitriptyline and Aminophylline.

5. Policy
5.1 Use of high alert medication shall be in accordance with manufacturer’s instructions,
Hospital Formulary, and when applicable, the Central Drug Committee (CDC)
guidelines.
5.2 The pharmacy department must provide general guidelines for the proper handling of
high Alert Medications including a defined list, in accordance with the FDA and
ISMP Standards.
5.3 High-Alert medications must be properly labeled with RED warning sticker “High-
Alert” to each designated drawer or cabinet where these medications are stored.
Restrict supply of high risk medications to areas of specified use where possible.
5.4 Concentrated electrolytes (Potassium & Sodium Phosphate, Potassium Chloride, and
Sodium Chloride above 0.9%) are High-Alert Medications and should not be stocked
in patient care areas except as part of the crash cart medications.
5.5 Some critical/particular care areas may stock limited quantities of these concentrated
electrolytes in a separate, locked and properly labeled cabinet away from the regular
wardstock medications and closely monitored by nursing and pharmacy staff.
5.6 Ensure high risk medicines and risk awareness components for medication
management are included in workforce orientation and ongoing education programs
on medication safety.
5.7 Remove the need for rapid mathematical calculation and reduce options and choices
by standardizing concentrations of medicines in solutions.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

5.8 All incidents regarding high-risk medicines must be reported to ensure appropriate
implementation of risk management or improvement strategies.

6. Procedure
6. 1 Managing High-Alert medications
6.1.1 High Alert Medications should have “HIGH ALERT MEDICATION”
labels on storage shelves, containers, product packages and loose vials or
ampoules.
6.1.2 High Alert Medications will be double checked before they are prepared,
dispensed and administered to the patients. All High Alert Medications issued
from the pharmacy will be counterchecked and verified by another pharmacy
staffprior to dispensing for the purpose of medication safety and accuracy.
6.1.3 Any changes of brand/color/preparation of High-Alert Medications will be
informed to the end users / wards / units, as soon as possible.
6.1.4 All equipment or devices used in the preparation and/or administration of
medications shall be calibrated and maintained according to Standard
Operating Procedure (SOP).
6.1.5 All staff involved in the handling of High Alert Medications shall be educated
on management guideline.

6.2 Strategies to avoid errors involving High-Alert Medications:

6.2.1 Procurement
6.2.1.1 Limit the drug strengths available in the formulary of each health
carefacility.
6.2.1.2 Avoid frequent changes of brand or color. Notify the end
userswhenever there are changes.
6.2.1.3 Inform all relevant personnel regarding new High Alert
Medicationslisted in the MoH formulary.
6.2.1.4 Encourage the purchase / ordering of equipment and consumables
withsafety features for safe drug administration.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

6.2.2 Storage
6.2.2.1 All personnel must read the High Alert Medication labels carefully
before storing to ensure medications are kept at the correct place.
6.2.2.2 All High Alert Medications shall keptin individually labeled
containers. Whenever possible avoid look-alike and sound-alike
drugs or different strengths of the same drug from being stored side
by side.
6.2.2.3 Use TALL-man lettering to emphasize differences in medication
names (e.g. DOPamine and DOBUTamine).
6.2.2.4 Limit ward’s floor stock drugs to standard requirement. Reduce the
quantity and variation of strength/preparation stocked.
6.2.2.5 Label all containers used for storing High Alert Medications as
“HIGH ALERT MEDICATION”.

6.2.3 Prescribing
6.2.3.1 Do not use abbreviations when prescribing High Alert Medications.
6.2.3.2 Specify the dose, route and rate of infusion for High Alert
Medicationsprescribed. (e.g.: IV Dopamine 5mcg/kg over 1
minute)
6.2.3.3 Prescribe oral liquid medications with the dose specified in milligrams.
6.2.3.4 Do not use trailing zero when prescribing. (e.g. 5.0 mg
can bemistaken as 50 mg)
6.2.3.5 Use computerized prescriber order entry as far as possible, to
eliminateillegible handwriting and misinterpretation of verbal
orders. Safety features should be incorporated in the computer
system for safe medication use.
6.2.3.6 Verbal/Telephone order for high alert medication is not allowed
exceptin emergency situation.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

6.2.4 Dispensing / Supply

6.2.4.1 All High Alert Medication containers, product packages and
loosevials or ampoules issued to wards/units shall be labeled as
“HIGHALERT MEDICATION” except for parenteral
nutrition preparations.
6.2.4.2 High Alert Medications to be dispensed to patients need not be
labeledas high alert.
6.2.4.3 High Alert Medications shall be counter checked before dispensing.
6.2.4.4 High Alert Medications shall be checked upon receiving by
thehealthcare providers.

6.2.5 Administration
6.2.5.1 The following particulars shall be independently double checked
against the prescription or medication chart at the bedside by two
appropriate persons before administration:
6.2.5.1.1 Patient’s name and ID
6.2.5.1.2 Name and strength of medications
6.2.5.1.3 Dose
6.2.5.1.4 Route and rate (pump setting and line placements
whennecessary).
6.2.5.1.5 Expiry date
6.2.5.2 Label the distal ends of all access lines to distinguish IV from
epidurallines.
6.2.5.3 Ensure no distraction during administration of medications to
patientsby implementing special measures (example: wearing
special apron).
6.2.5.4 Return all unused or remaining specially formulated
preparations tothe pharmacy when no longer required.
6.2.5.5 Ensure administration of cytotoxic drugs, parenteral nutrition etc.
likemedicines is done by trained personnel.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

6.2.5.6 Avoid ordering High Alert Medications verbally. In

cases ofemergency, phone orders have to be repeated
and verified.
6.2.6 Monitoring
6.2.6.1 Closely monitor vital signs, laboratory data, patient’s response
beforeand after administration of High Alert Medications.
6.2.6.2 Keep antidotes and resuscitation equipment in wards/ units.

6.2.7 Training
6.2.7.1 All personnel shall be trained prior to handling of High-Alert
Medications and documentation kept. Staff must be trained to
preventpotential errors and enable them to respond promptly
when mistakes do occur.
6.2.8 Information
6.2.8.1 References or dilution guide shall be made available in the wards
andpharmacy.

6.2.9 Patient Education

6.2.9.1 Educate patient and family members/caregivers on:
6.2.9.1.1 Name and purpose of medications.
6.2.9.1.2 How much and when to take the medications.
6.2.9.1.3 How to take their medications.
6.2.9.1.4 Common side effects.
6.2.9.2 Encourage patient and family involvement by:
6.2.9.2.1 Asking what medications are being given and why they
arebeing given.
6.2.9.2.2 Ensuring positive identification before
receivingmedications.
6.2.9.2.3 Storage of High Alert Medications.
6.2.9.2.4 Disposal of expired / unused High-Alert Medications.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

6.2.10 Evaluation of Action:

6.2.10.1 Monitor adverse drug reactions and medication errors related to
HighAlert Medications.

7. Responsibility
7.1 Health Care Providers - directly involved in procedures Shall:
7.1.1 Deal with prescribing, dispensing, preparing, administering, storing of high
alertmedications to patients.

7.2 Admin level / Nursing / Medical Service / Pharmacy Section In-charge Shall:
7.2.1 Allocate resources in coordination with the hospital admin to support the
implementation of the medication policies.
7.2.2 Deal with higher authorities of the hospital regarding any series concerns
duringthe policy implementation.
7.2.3 Coordinate with the section focal points confirming all the staffs are fully
informed of their role in maintaining the required standard practice.
7.2.4 Lead to strategies and innovations to improve current practice.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

8. Document History and Version Control Table

Document History and Version Control

Version Description of Amendment Author Review Date

Policy and Procedure

1 Initial Release March 2021
team (P&MS)

Update and Review Policy and Procedure July 2025

2
team (P&MS)

Written by Reviewed by Approved by

Policy and
Procedure team Najla Al Zadjali Dr. Bader Al Habsi
(P&MS)

9. Related Documents
9.1 Al Masarra Hospital, Nursing Department -Medication Administration Policy and
Procedure. (Hospital Local Site).
9.2 Al Masarra Hospital, Pharmacy Department–Medication Storage Policy.
9.3 Al Masarra Hospital, Pharmacy Department - Medication Ordering Policy.
9.4 Al Masarra Hospital, Pharmacy Department - Medication Orders Review Policy.
9.5 Al Masarra Hospital, Pharmacy Department - Medication Error Reporting Policy.
9.6 Al Masarra Hospital, Pharmacy Department –Look-Alike / Sound-Alike
MedicationsPolicy.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

10. References:

Year of
Title of book/Journal/Website Author Page
publication

MoH –
High -Alert Medications DGMS, MoH, Muscat
DGMS-PH-35

High-Alert Medications Policy Department of Health,

2014
Australia.

Management of High-Alert Medications Albert Health Services 2015

Guideline on Safe Use of High-Alert

MoH, Malaysia 2011
Medications.

Guidelines FDA and ISMP -

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Appendices

Appendix 1: Available Formulations in MoH

Classes/ Categories of Medications Available formulations in the MOH

Adrenaline 500 mcg/0.5ml 1:1000, 0.5ml inj

Adrenergic agonists, IV:
Adrenaline (1:1000) 1 mg/ml 1 ml, (i.m. / s.c) adrenaline
Adrenaline
1:10,000 10 ml.
(IV and SC)
1 mg/10ml, Preloaded syringe.
Noradrenaline acid Tartarate 2 mg/ml (equivalent to
Noradrenaline acid Tartarate
noradrenaline base 1 mg/ml), 2 - 4 ml ampoule
Phenylephrine Phenylepherine 1 % 1 ml inj
Isoproterenol hydrochloride Isoproterenol hydrochloride injection 0.2 mg/ml inj
Adrenergic antagonists, IV:
Labetalol hydrochloride i/v 5mg/ml 20ml. Inj
Labetalol hydrochloride
Metoprolol Metoprolol 1mg/ml iv inj
Propranolol Propranolol hydrochloride 1mg/ml 1ml. Inj
Phentolamine Mesilate Phentolamine Mesilate 10mg/ml, 1ml. Inj
Antiarrhythmics, IV:
Verapamil hydrochloride 2. 5 mg/ ml. 2ml. Inj
Verapamil hydrochloride
Antiretroviral agents All formulations
Antithrombotic agents: Tab. Warfarin Sodium 1mg
1.Anticoagulants: Tab Warfarin Sodium 2mg
Warfarin Tab Warfarin Sodium 5mg.Tab
Heparin 1000 iu/ml 5ml inj
Unfractionated Heparin Heparin 25000 iu/ml 5ml inj
Heparin 5000 iu/ml 5ml,inj
Heparin LMW (enoxaparin, Dalteparin or Tinzaparin )
20,000-30,000 I.U. multidose.
LMW Heparin
Heparin LMW ( enoxaparin, Dalteparin or Tinzaparin) 4,000
- 5,500 I.U, 6000 IU, 8000 IU, 10,000 I.U
Factor Xa inhibitors: Fondaparinus sodium 5 mg/ml, 0.5 ml (2.5 mg) prefilled
Fondaparinux syringe

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Classes/ Categories of Medications Available formulations in the MOH

Direct thrombin inhibitors:

Argatroban 100mg/ml, 2.5ml tab
Argatroban
Thrombolytics:
Alteplase 50mg inj
Alteplase
Reteplase 10 units 1.16 gm / ml powder for reconstitution
Reteplase
pack of 2 vials with diluent.
Cardioplegic solutions All formulations
Chemotherapeutic agents, parenteral and All formulations
oral
Dextrose, hypertonic, 20% or greater All formulations
Dialysis solutions (peritoneal, All formulations
hemodialysis)
Epidural or intrathecal medications All formulations
Hypoglycemics, oral All formulations
Immunosuppressant agents All formulations
Digoxin 0.25 mg/ml 2ml inj
Inotropic medications, IV:
Digoxin 0.25mg. Tab
Digoxin, oral and IV
Digoxin 0.0625mg Tab
Dobutamine Dobutamine hydrochloride 250 mg per vial or ampoule
Dopamine Dopamine hydrochloride 40mg/ml 5ml. Inj
Insulin, SC and IV All formulations
Moderate sedation agents, IV:
Midazolam 5mg/ml. 3ml
Midazolam
Moderate sedation agents, oral. For Chloral Hydrate 500 mg/5ml, 200 ml.
children: Chloral hydrate syrup Chloral Hydrate elixir 150 ml 143.3mg/5 ml
Midazolam Midazolam 2.5mg/ml.100ml
Narcotics/ Opioids, oral, IV and
Narcotics/ opioids, oral, iv and transdermal
transdermal.
Rocuronium 10 mg/ ml, 5 ml
Neuromuscular blocking agents
Vecuronium bromide 10mg.
Parenteral nutrition preparations Parenteral nutrition preparations

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Classes/ Categories of Medications Available formulations in the MOH

Pregnancy category X drugs All formulations

Radiocontrast agents, IV Radiocontrast agents, iv
Sterile water for injection, inhalation and
Sterile water for injection, inhalation and irrigation
irrigation.
Sodium chloride for injection, hypertonic,
All formulations
greater than 0.9% concentration.

Specific Medications Available formulations in the MOH

Carbamazepine Controlled Release 100 Mg. Tab

Carbamazepine Controlled Release 200 Mg. Tab
Carbamazepine Controlled Release 400 Mg Tab
Carbamazepine
Carbamazepine 100mg. Tab Carbamazepine 200mg. Tab
Carbamazepine 100mg/5ml. (2%) Liquid 300ml.
Carbamazepine Liquid 100 Mg/ 5 Ml. (2%) 100 Ml.
Iron Dextran Injection 20ml.
Iron Dexran, Parental
Iron Dextran Injection 5ml.
Magnesium Sulphate (50 %) 1 Gm - 2 Ml Inj
Magnesium Sulphate Magnesium Sulphate ( 50 % ) 5 Gm - 10 Ml. Inj Magnesium
Sulphate ( 50 %) 2.5 Gm- 5 Ml. Inj
Metformin Metformin Hcl. 500mg. Tab
Methotrexate 2.5mg Tab
Methotrxate Oral
Methotrexate Suspension
Oxytocin Synthetic 10 IU. Inj
Oxytocin Oxytocin 5IU/Ml, Ergometrine Maleate 500 Micrograms/
Ml, 1 Ml. Inj
Potassium Phosphate Injection Potassium Phosphate Usp 5 -10 Ml.
Potassium Chloride 15% 10ml
Potassium chloride for injection
Potassium Chloride 2 Meq/Ml. 20 Ml
Promethazine Hydrochloride 25mg/Ml Ml. Inj
Promethazine IV
Promethazine Hydrochloride 50 Mg, 1-2 Ml.Tab
Propylthiouracil Propylthiouracil 50 Mg. Tab

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Appendix 2: High-Alert Medications – Common Risk Factors

Common Risk Factors

Common risk factors associated with High Alert Medications are as follows:
 Poorly written medication orders.
 Incorrect dilution procedures.
 Confusion between IM, IV, Intrathecal, epidural preparations.
 Confusion between different strengths of the same medications.
 Unclear labeling on concentration and total volume of medications.
 Wrong infusion rate.
 Look alike or sound alike product and similar packaging.

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Appendix 3: Audit Tool

Pharmacy and Medical Stores, Al Masarra Hospital MoH

High-Alert medications - Audit Tool

Audit
S.N. Process Standard / Criteria Yes Partial No N/A Comment
Observation Are prominent High-Alert
warning labels applied on storage
1 Document of shelves, containers, product
Review packages, loose vials or
ampoules?
Observation Are all High-Alert medications
are stored properly and restricted
Interview access to authorized/qualified
2
staff?
Document
Review
Observation Is the prescribing practice for
High-Alert medications are
Interview appropriate and there are no
3
prohibited abbreviations,
Document symbols and dose designations
Review are not used?
Observation While dispensing/administering
High-Alert medications, are there
4 Interview established check system
whereby one staff prepares the
dose and another staff reviews it?
Observation Are all controlled Narcotic drugs
Interview separated and securely stored?
5
Document
Review
Observation High – Alert medication
evaluation of action are
Interview satisfactory?
6
Document (Monitoring of Adverse Drug
Review Reaction / Medication errors etc.
and its documentations)

Checked by (Name and Signature): …………………………….. Date: …………………....

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Appendix 4. Document Request Form

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Policy and Procedure of High Alert Medications Effective Date: July 2022
Review Date: July 2025

Appendix 5. Document Validation Checklist

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