Samuel Budi Harsono,M.Si., Apt.

Divisi Farmakologi dan Farmasi Klinik

UNIV. SETIA BUDI SURAKARTA
 Introduction

all hospitals pharmacy still complainhng of

medications errors problems which lead to
increasing number of patients die until now.

The research for the methods or ways to reduce

these medications errors is a great challenge

Sowe must know more information about

medications that consider as High Alert
Medications and how to deal with them?
6 IPSG ( VERSI JCI, 2011)
 Key points

Definition.
High alert medications.
The top five high-alert medications.
Reduce the risks of high-alert drugs.
Safeguards for the use of high alert
medications.
 I. Definition
High Alert Medications :

Drugs that bear a heightened risk of causing

significant patient harm when they are used in error.
Although mistakes may or may not be more common
with these drugs, the consequences of an error are
clearly more devastating to patients.
 II. High Alert Medications
Classes/Categories of Medications
Adrenergic agonists I.V (e.g, epinephrine, phenylephrine, norepinephrine ).

Adrenergic antagonists I.V ( e.g, propranolol, metoprolol, labetalol )

Anasthetic agents: inhaled and IV ( e.g, propofol, ketamine )

Antiarrhythmics, I.V ( e.g, lidocaine, amiodarone ).

Anticoagulant : (e.g, heparin, warfarin ).

Chemotherapeutic agents : parentral and oral.

Oral hypogylcemics.

Inotropic medications I.V ( e.g, digoxin , milrinone ).

Moderate sedation agents I.V (e.g, midazolam), Oral (e.g, chloral hydrate)
Narcotics/Opiates I.V, transdermal and oral.

Neuromuscular blocking agents ( e.g, succinylcholine).

 Cont..

Specific medications
Colchicine injection .

Insulin : S.C and I.V.

Magnesium sulfate injection.

Methotrexate : oral ( non oncologic use ) .

Oxyticin I.V.

Nitroprusside sodium for injection.

Potassium chloride for injection .

Promethazine I.V.

Sodium chloride for injection.

III. The top five high-alert medications

1- Insulin.

2- Opiate and Narcotics.

3- Injectable Potassium chloride or phosphate.

4- Injectable Anticoagulant.

5- Sodium chloride solution above 0.9%.

 III. The top five high-alert medications

1- Insulin

Hypoglycemia is the most common complication of any

insulin therapy.

Factors contributing to harm :

- Complexity of dosing.

- Frequent monitoring.

- Pharmacokinetics differ based on insulin type.

 Cont..
- Many insulin products available :
( look alike sound alike names )

- Lack of dose check systems

- Insulin and heparin vials kept in close proximity to each other

on a nursing unit, leading to mix-ups.

- Use of "U" as an abbreviation for "units" in orders (which can

be confused with "O," resulting in a 10-fold overdose)

- Incorrect rates being programmed into an infusion pump.

 Cont..
2- Opiates and Narcotics

Factors contributing to harm :

Calculation errors.

IV to PO conversion errors.

Errors converting potency when changing from

one narcotic to another.

Many dosage forms.

 Cont..

- Parenteral narcotics stored in nursing areas as

floor stock.

- Confusion between hydromorphone and morphine.

- Patient-controlled analgesia (PCA) errors

regarding concentration and rate.

Adverse effet :

- Respiratory depression
- Confusion
- Lethargy
 Cont..
3- Injectable Potassium Chloride or
Phosphate

Common Risk Factors

- Storing concentrated potassium chloride/phosphate

outside of the pharmacy.

- Requests for unusual concentrations.

Adverse effect :
Cont..

1- Muscular or respiratory paralysis.

2- Mental confusion.

3- Hypotension.

4- Cardiac arrhythmia.

5- Heart block.
 Cont..
4- Injectable anticoagulant ( Heparin )

Common Risk Factors

Narrow therapeutic range.

Complex dosing.
Frequent monitoring.
Patient compliance.
Many interaction :
Other prescription medication.

OTC medications.
Herbal products.
Food.
 Cont..
Common Risk Factors

- Unclear labeling regarding concentration and total

volume.

- Multi-dose containers.

- Confusion between heparin and insulin due to

similar measurement units.
 Cont..
5- Sodium chloride solution above
0.9%

Common Risk Factors

- Storing sodium chloride solutions (above 0.9%) on

nursing units.
- Large number of concentrations/formulations
available.
- No double check system in place.
 IV. Reduce the risks of high-alert
drugs
Three formulas:

1. Standardize error-prevention processes.

2. Make errors apparent.
3. Minimize the consequences of errors that

reach the patient.

 Cont..
1. Standardize error-prevention
processes

Technological aids:

1- Computerized prescriber order entry (CPOE)

2- Bar coding

Make patient information readily accessible:

 Cont..
2. Make errors apparent

a. Perform independent double checks

b. Rely on redundancies.

c. Listen for bells and whistles.

 Cont..
a. Perform independent double checks

Have another person verify the medication order and

infusion pump setting :

just before you start an infusion.

every time you change an infusion rate.
every time you replace an empty infusion bag or
cassette.

Use this method exclusively for high-alert drugs to avoid

double-check fatigue and complacency.
 Cont..
b. Rely on redundancies

Match high-alert drug orders to the patients diagnosis,

the drugs indication, and vital patient information.

If possible, avoid verbal orders. If theyre necessary,

write down the order in the chart and then read back:

patient name
drug order as written
spelling of the drug name
 Cont..
3. Minimize consequences of errors

A. Closely monitoring the patients

- level of consciousness
- vital signs
- respiratory status
- lab results

B. Ensuring that reversal agents and resuscitation

equipment are readily available
 V. Safeguards for the use of high alert
medications

- Removal high concentrate electrolytes (e.g. potassium

chloride, potassium phosphate and sodium chloride)
from all nursing units.

- Stop using dangerous abbreviations such as u.

- Use of a leading zero before a decimal place.

- Review the hospital formulary for sound-alike and

look-alike medications.
LASA/ SALAD
LASA/ SALAD
 Cont..
- Use of tall man letters for sound-alike and look-alike names
(e.g. DOBUTamine and DOPamine).

- Careful review of how products are arranged on shelves to

avoid similar packaged or sound-alike medications being side by
side.

- Use flow-control pumps for continuous intravenous (I.V.) infusions.

- Educate patients and family and encourage their participation in

care.
STERILE LABEL FOR
CONTAINER
KEBIJAKAN
Buang obat atau cairan segera bila
ditemukan tidak berlabel.
Vial/ ampul / wadah obat atau cairan
jangan dibuang sampai prosedur atau
tindakan selesai, terutama di kamar
operasi atau ruang prosedur
Label pada kontainer steril harus
dibuang pada setiap selesai suatu
prosedur/tindakan
PEMBERIAN OBAT PERLU DIWASPADAI
1. Penyiapan Obat yang Perlu Diwaspadai (High Alert) di Ruang
Perawatan
Penyiapan dan pemberian obat kepada pasien yang perlu diwaspadai
termasuk elektrolit konsentrasi tinggi harus memperhatikan kaidah
berikut :
a)Setiap pemberian obat menerapkan PRINSIP 7 BENAR
b)Pemberian elektrolit pekat harus dengan pengenceran dan
penggunaan label khusus.
c)Pastikan pengenceran dan pencampuran obat dilakukan oleh orang
yang berkompeten.
d)Pisahkan atau beri jarak penyimpanan obat dengan kategori LASA
e)Tidak menyimpan obat kategori kewaspadaan tinggi di meja dekat
pasien tanpa pengawasan.
f)Biasakan mengeja nama obat dengan kategori obat LASA / NORUM
(Look Alike Sound Alike = Nama Obat RUpa Mirip), saat memberi /
menerima instruksi.
HAL-HAL YANG PERLU DIPERHATIKAN
Setiap depo farmasi, ruang rawat, poliklinik harus memiliki
daftar obat High alert
1.Setiap tenaga kesehatan harus mengetahui penanganan
khusus untuk obat high alert
2.Prosedur peningkatan keamanan obat yang perlu
diwaspadai dilakukan mulai dari peresepan, penyimpanan,
penyiapan di farmasi dan ruang perawatan dan pemberian
obat
3.Obat high alert disimpan ditempat terpisah, akses terbatas,
diberi label High alert
4.Pengecekan dengan 2 (dua) orang petugas yang berbeda
untuk menjamin kebenaran obat high alert yang digunakan
5.Tidak menyimpan obat kategori kewaspadaan tinggi di meja
dekat pasien tanpa pengawasan
 Conclusion
- Use of visible coloured auxiliary warning
labels.

I wish to apply this procedure in this

hospital.
 KESIMPULAN lanjutan
Penggunaan dan pengelolaan High Alert Medication
dengan tepat dapat mengurangi medication error yang
dapat mengakibatkan bahaya pada pasien bahkan
sentinel event.

RS harus mengembangkan kebijakan dan prosedur

terkait secara kolaborasi dan koordinasi antar bagian,
menyediakan fasilitas pendukung,
mengimplementasikannya kedalam praktek sehari-hari,
memonitor kepatuhan staf terhadap SOP, mengevaluasi,
dan menindak lanjuti bersama jika ditemukan
ketidaksesuaian dengan kebijakan dan prosedur yang
berlaku ( siklus PDCA )
 References
1. 5 Million Lives Campaign Getting Started Kit: Prevent Harm from
High-Alert Medications How-to Guide. Institute for Healthcare
Improvement,
2007.://www.ismp.org/newsletters/acutecare/articles/20070517.
asp
2. Cohen.M.R., Practical Error Prevention Strategies for High Alert Drugs.
http://www.ashp.org/DocLibrary/Policy/Anticoagulation/HighAlertMedic
ationsandthePharmacistsRoleinAnticoagulationSafety.aspx . Retrieved
21 Oktober 2009.
3. Institute for Safe Medication Practices. List of High Alert Medication.
http://www.ismp.org/Tools/highalertmedications.pdf. Retrieved 21
Oktober 2009
4. JCI. 2007. Joint Commission International Accrediatation Standards
Accrediatation Hospitals. 3rd edition. Effective Januari 2008 . Illinois.
USA.
5. JCI. 2007. Meeting the International Patient Safety Goals. Illinois. USA