High-Alert Medication List…Only Effective when Combined with Risk-Reduction Strategies

September 30, 2021

High-alert medications are 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 with these medications are clearly more devastating to patients. This is borne out repeatedly by reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP).

Based on error reports submitted to the ISMP MERP, reports of harmful errors in the literature, and input from practitioners and safety experts, ISMP established lists of high-alert medications used in various healthcare settings, including community/ ambulatory care. The original ISMP List of High-Alert Medications in Community/ Ambulatory Care Settings was developed in 2008. To update the list, practitioners were surveyed. To assure its relevance and completeness, the clinical staff at ISMP, members of the ISMP Medication Safety Alert! Community/Ambulatory Care Clinical Advisory Board, and safety experts throughout the US were asked to review the list, including proposed additions to the list, and provide us with feedback and suggestions about any changes. The updated 2021 list can be found on page 5 of the pdf of this newsletter and on our website, and reflects the collective thinking of all who provided input.

ISMP is relying on community and ambulatory care settings to use this updated list as a resource to identify the high-alert medications prescribed, stored, dispensed, and/or administered in their organizations or the facilities they serve. However, this is just the first step in safeguarding the use of high-alert medications. Without highly effective processes for staff to follow to detect and prevent errors, a list will do little to increase medication safety. Similarly, a list of high-alert medications and related risk-reduction strategies that are not well known and understood by all staff will have little impact on safety.

Implement Risk-Reduction Strategies

The purpose of identifying high-alert medications is to establish specific safeguards to reduce the risk of harm with these drugs in all phases of the medication-use process. Strategies should: 1) eliminate or prevent the errors, 2) make the errors visible, and/or 3) mitigate the harm from errors when they occur. To be effective, all of the following components need to be considered:

Understand the causes of errors. Effective strategies must address the underlying system-based causes of errors with each type of high-alert medication or class of medications. To learn about the causes of errors, review internal medication error-reporting data and the results of any applicable root cause analyses. Equally important, a search of the external literature, including this newsletter, should be completed to learn about errors with high-alert medications that have occurred elsewhere. Taking the step to understand the causes of errors in your facility should not be skipped. If you cannot describe the ways that errors have happened or could happen, your strategies may not be effective at targeting the risks within your organization.

Layer comprehensive strategies. A single risk-reduction strategy for each high-alert medication is rarely enough to prevent harmful errors. The keys to success include many of the following components:

A variety of risk-reduction strategies should be used simultaneously to reduce the risks associated with a particular high-alert drug. David Marx, a culture and system reliability expert, likens the relative safety of a system to a dice game—with each dice representing a risk-reduction strategy in the layer of the safety net.¹ Rolling a snake eye (one) represents failure; rolling anything else represents success. The more dice you roll, the less the risk of getting all snake eyes, and the safer the system will be due to the simple power of math. As noted by Marx, “in no place is the single dice more deadly than that of healthcare….”¹ Roll a single die, and harm is only a single failure away. Design the safety system to be 3, 4, or 5 dice away from harm, and it will vastly improve safety.
Risk-reduction strategies should impact as many steps of the medication-use process (e.g., prescribing, transcribing, storing, dispensing, administering, and monitoring) as feasible given the underlying causes.
Choose strategies that provide reliable protection each time (e.g., using automation, technology alerts), and limit reliance on strategies that require staff to follow rules/policies or rely on memory to avoid error. Please reference Table 1 (also on pages 3 and 4 of the PDF of the newsletter) when risk-reduction plans are being developed.
The best strategies will be sustainable over time.

Communicate the List and Strategies

A list of high-alert medications and associated risk-reduction strategies that is not well known to all who touch the medication-use process will have little impact on patient safety. Be sure to discuss with all staff why the list and strategies are important, whom they will impact, and why they were created in the first place. This will help them understand their value, the medication errors and patient harm they will prevent, and why it is critical to implement each of the risk-reduction strategies. Also, there is no point in having the high-alert medication list and associated risk-reduction strategies buried in a policy and procedure manual. Make the document electronic and mobile-friendly so that staff can easily access it and quickly search it whenever needed. Print it out and place it in areas visible to staff.

Assess the Effectiveness of Strategies

Regularly ask your staff for ideas and feedback about the high-alert medication list and associated risk-reduction strategies. Find out any concerns they may have at staff meetings, via anonymous surveys, during leadership rounds, via suggestion boxes, or using any other means of communication. This is essential not only to keep all staff engaged, but also to hear if there are any barriers to implementation of the planned risk-reduction strategies. Use this information to make any necessary adjustments to the list and strategies.

Also, routinely audit practice to determine the effectiveness of risk-reduction strategies for the identified high-alert medications. The results should be shared regularly with leadership or at other appropriate meetings or huddles. Reviewing the effectiveness of the established safeguards is vital to the ongoing success in lowering the risk of medication errors with high-alert medications.

Reference

Marx D. Play with three dice, when you can. What We Believe. Outcome Engenuity. 2017;1(3):1-2.