Medication Safety and High Alert Medications, Lecture notes of Medicine

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Medication Safety and

High Alert Medications

Objectives

At the completion of this presentation participants should:

1. Be able to identify what a high alert medication is and

what medications are considered high alert at

Nebraska Medicine (NM)

2. Identify best practice recommendations and

organizational safeguards used to reduce risk with

high alert medications

3. Understand how to safely evaluate, order and monitor

high risk medications

4. Understand the importance of medication warnings

and the work being done to evaluate warnings to

make existing warnings more meaningful

High Alert Medications

• Strategies and safeguards implemented for high alert medications
  • Use of “High Alert” stickers in applicable storage areas
  • Use of red bins in applicable storage areas
  • Labeling of applicable medications with a “High Alert” sticker when not already labeled as such by the manufacturer
  • High alert medications not stored in a lock lidded pocket must be scanned when removed from the automated dispensing cabinet
  • Whenever possible, ordering is restricted to order-sets
  • When ordering a high alert medication the provider is required to select an appropriate indication
  • Medications identified as high alert are labeled as such within One Chart
  • Smart infusion pumps with guardrails are used
  • Selected high alert medications require independent dual clinician verification prior to administration

High Alert Medications

• Per organizational policy MM02 High Alert Medications, the

following medications and medication classes have been

identified as being high alert at Nebraska Medicine

• Antithrombotics and specific anticoagulant agents
• Insulin
• Adrenergic agonists and inotropic agents
• Anesthetic and sedative agents
• Neuromuscular blocking agents
• Chemotherapy and other cytotoxic agents
• Concentrated electrolyte solutions
• Parenteral nutrition
• Prostacyclin analogues
• Epidural/intrathecal medications and patient controlled analgesia
• Sodium citrate/calcium infusions for CVVHD
• Nonformulary infusions

Heparin

• UFH for continuous IV infusion should be ordered in a

weight based fashion

• Non weight-based dosing for small and pediatric patients is

dangerous!

• Pharmacokinetics is non-linear: a fixed dose of heparin will

not predictably result in a fixed response

• Non-weight based heparin infusions are allowed for

procedures related to thrombolysis IR or vascular patency.

• These infusions must be on a dedicated pump, and the

pump must be appropriately labeled.

• Weight-based dosing of UFH for continuous infusion allows

for uniform use of smart pump drug libraries

Heparin

• UFH administered by continuous IV infusion requires

laboratory monitoring

• Anti-Xa assay (heparin quantitative assay; HEPQT) is the

“gold standard”. A therapeutic aPTT is defined as one which

correlates to a heparin quantitative assay of 0.3-0.7 IU/mL.

• Anti-Xa assay is less sensitive to some confounders that can

affect aPTT (anti-phospholipid antibodies, DIC, congenital

coagulation factor deficiency, etc.)

• Per the Pediatric Quality Committee only HEPQT can be

used to monitor pediatric patients on heparin at NM

• Laboratory monitoring should also include:
  • Baseline aPTT to confirm it is within normal range and rule out potential confounding conditions
  • Platelet count prior to initiation and regularly to detect possible heparin-induced thrombocytopenia (HIT)
  • Hemoglobin

Heparin

• When UFH is used per protocol, a provider must be

contacted by a pharmacist or nurse in the following

situations:

• When the patient weight is 177.8kg (VTE) or 181.9 kg

(ACS) or greater at initiation

• Heparin quantitative assay results meet/exceed 1.

units/mL, or the PTT results meet/exceed 200 seconds

• When the patient shows signs of active bleeding the

nurse will contact the provider

• When infusing doses exceed the soft and/or hard

maximum guardrail smart infusion device limit, the

pharmacist will notify the provider. This is required for

dose increases only

Heparin

• DVT/PE Treatment
  • Achieving therapeutic anticoagulation within 24 hours of

starting UFH improves outcomes (recurrent/progressive

DVT/PE, death from PE, post-thrombotic syndrome) when

treating DVT/PE^1

• Use of an algorithm that uses weight based heparin

dosing + standardized dose adjustments is more likely to

achieve therapeutic anticoagulation in the first 24 hours^2

• Exceptions might be necessary for patients with high

bleeding risk (thrombocytopenia, additional anti-platelet

agents, etc.)

1. Hull et al. Arch Intern Med 1992; 152: 1589
2. Raschke et al. Ann Intern Med 1993; 119: 874

Heparin

• Custom UFH continuous infusion
  • If the custom heparin protocol is used:
    • The provider must order a discrete dose and indicate

an appropriate therapeutic goal based off of Heparin

Assay or aPTT. No custom algorithms will be

allowed

• When a custom heparin infusion is ordered the

provider must be contacted for each lab value outside

of the ordered goal

Anticoagulant Exclusion Order

• A “ No anticoagulant or antiplatelet medications” order is available if a provider determines that neither anticoagulant nor antiplatelet medications should be administered to a patient
• The exclusion order is similar to other medication orders, and once ordered will fire an alert to all end-users that attempt to order a medication that has been deemed inappropriate using the exclusion order
• Per policy (MS 66 Anticoagulation Management) the team indicated in the Service/Team responsible for order field should be contacted prior to making any changes to the exclusion order

1. Low prioritization of glycemic control in hospitalized patients
2. Medical status changes leading to alterations of insulin requirements a. Release of counter-regulatory hormones b. Decrease in insulin requirement
3. Variation of nutritional status a. Changes in caloric intake b. Transitions in the type of nutrition provided
4. Medication effects

a. Increased risk for HYPER glycemia i. Calcineurins (e.g., tacrolimus, cyclosporine) ii. Catecholamines iii. Corticosteroids b. Increased risk for HYPO glycemia i. Insulin ii. Quinolone antibiotics iii. Tapering OR Withdrawal of corticosteroids iv. Sulfonylureas

5. Knowledge deficits of healthcare providers

Barriers to Glycemic

Control

• Insulin is the PRIMARY treatment option for diabetics while they are hospitalized
• Patients admitted to the hospital should have previous oral/non-insulin pharmacotherapy DISCONTINUED
• Institutional blood sugar goal for diabetic patients:

 70 – 180 mg/dL

• Consider the BBCs of insulin therapy in ALL Type 1 and most Type 2 hospitalized diabetic patients:

 B asal : long acting (insulin glargine) / intermediate

acting (NPH)

 B olus [if eating]: rapid acting (insulin lispro)

 C orrection scale : rapid acting (insulin lispro)

Insulin Background

Joint Commission Requirements

Related to Diabetes Management

• Documentation of HbA 1 C:

 MUST be drawn on ALL patients with diabetes

if not current within the last 90-days

 If available from an outside facility

 The result MUST be documented in the electronic medical record (EMR)

 If not drawn secondary to confounding results

(e.g., recent blood transfusion)

 The reason MUST be documented in the EMR

 If the pre-checked box on the “General

Subcutaneous Insulin” order set is UNCHECKED

 The reason MUST be documented in the EMR

• Decide if the patient needs scheduled basal insulin
• When starting insulin in patients, utilize weight-based estimates

Dosing of Insulin

If the patient has these features present...

Total Daily Dose (TDD) of insulin (units/kg) Malnourished, elderly (> 70 y.o.), CKD (on dialysis), severe liver disease

Normal-weight patients (including Type 1 diabetics) (^) 0. Overweight (^) 0. Obese, high dose steroids, or other markers of significant insulin resistance

Use a basal insulin in patients with known diabetes if...

Use a basal insulin in patients with or without a history of diabetes if...

• Type 1 diabetic OR otherwise markedly insulin deficient
• Patient already requires insulin
• Poor control despite oral agents
  • The patient consistently has a fasting blood glucose out of the target range