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How Can Harm from High Risk Medications be Prevented?

Executive Summary

Most adverse drug reactions are not only preventable but are caused by the same group of high-risk medications. These medications are most likely to cause frequent and serious harm to patients, even when used as intended. This leads to patient suffering and additional healthcare costs. Though mistakes may not be more common in the use of these medications, when errors do occur, the impact on the patient can be significant. This also refers to medications that bear a heightened risk of causing significant harm to individuals when they are used in error. The following strategies can help to reduce harm from high-risk medications:  

  1. Prevent Harm;
  2. Identify Harm;
  3. Mitigate Harm; and
  4. Implement and Sustain Change.

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Prevent Harm

  • Develop order sets, preprinted order forms, and clinical pathways or protocols to establish a standardized approach to treating patients with similar problems, disease states, or needs.
  • Minimize variability by standardizing concentrations and dose strengths to the minimum needed to provide safe care.
  • Consider centralized pharmacist- or nurse-run anticoagulation, insulin management, and pain management services.
  • Include reminders and information about appropriate monitoring parameters in the order sets, protocols, and flow sheets.
  • Consider protocols for vulnerable populations such as elderly, pediatric, mental health and obese patients.
  • Adopt TALL man lettering for pharmacy produced labels to differentiate drug names with potential for mix-up.
  • Use evidence-based protocols.


Identify Harm 

  • Include reminders and information about appropriate monitoring parameters in the order sets, protocols, and flow sheets.
  • Ensure that critical lab information is available to those who need the information and can take action.
  • Implement independent double-checks where appropriate.
  • Instruct patients on symptoms to monitor for side effects and when to contact a healthcare provider for assistance. A medication reconciliation form may be useful in this regard.

Mitigate Harm 

  • Develop protocols allowing for the administration of reversal agents without having to contact the physician.
  • Ensure that antidotes and reversal agents are readily available.
  • Have rescue protocols available.
  • Conduct an interdisciplinary failure modes and effects analysis (FMEA) within your facility to identify sources of failure with the use of high-alert medications.
  • Measure and report medication errors when they occur. The trigger tool for measuring adverse events may be helpful in this regard.

Implement & Sustain Change

Improving the management of high-alert medications can seem like an overwhelming challenge. Many hospitals may have already made changes; others may still be struggling. Even if you have made changes, have you been able to sustain the improvement? If your team tries to do everything all at once, it may well prove overwhelming. Here are a few tips from those who have already achieved success in reducing harm from high-alert medications:

  • Obtain support from administrative and clinical leadership (Patient Safety Leadership Walkarounds are a great starting place).
  • Design your process and standardization according to evidence-based medicine.
  • Find a champion.
  • Education and training are necessary, but are not sufficient alone to ensure reliable application of a protocol.
  • Engage front-line staff in designing the process.
  • Use the Model for Improvement or some other proven improvement methodology.