1. HIGH ALERT

2. Medication Error
A medication error is any preventable
event that may cause or lead to
inappropriate medication use or patient
harm.
DEFINITION OF MEDICATION ERROR
HIGH ALERT MEDICATION
It can involve any one of the following processes:
Prescribing, Ordering, Dispensing, Distribution, Preparation,
Administration, Labelling, Packaging, Nomenclature,
Communication, Education, Use And Monitoring Of Treatment

3. • High-alert medications are medications that are
most likely to cause SIGNIFICANT HARM to the
patient, even when used as intended.
• Although any medication used improperly can cause
harm, high-alert medications cause harm more
commonly and the harm they produce is likely to be
more serious and leads to patient suffering
and additional costs associated with care of these
patients.
WHAT IS HIGH ALERT MEDICATION

4. LIST OF HIGH ALERT MEDICATION
THAT ARE AVAILBLE @ HBUK
1. Adrenaline 1mg/ml Inj
2. Cobra Antivenom Inj
3. Dextrose 30% Inj
4. Dextrose 50% Inj
5. Digoxin 0.5mg/2ml Inj
6. Dobutamine 250mg/20ml Inj
7. Dopamine 200mg/5ml Inj
8. Heparin 5000 unit/ml Inj
9. Actrapid 1000unit/10ml Inj
10. Midazolam 5mg/ml Inj
11. Morphine 10mg/ml Inj
12. Noradrenaline 4mg/4ml Inj
13. Pit Viper Antivenom Inj
14. Potassium Chloride 1Gm/10ml Inj

5. COMMON RISK FACTORS
• Poorly written medication orders
• Incorrect dilution procedures
• Confusion between IM, IV, intrathecal, epidural
preparations
• Confusion between strengths of the same medications
• Ambiguous labeling on concentration and total volume
of medications
• Wrong infusion rate
• Look alike or sound alike product and similar
packaging
COMMON RISK FACTORS

6. STRATEGIES TO AVOID ERRORS
INVOLVING HIGH ALERT MEDICATION
 All High Alert Medication containers, product packages and loose vials or
ampoules stored must be labeled as ‘HIGH ALERT MEDICATION’
 All personnel should read the High Alert Medication labels carefully
before storing to ensure medications are kept at the correct place
 All High Alert Medications should be kept in individual labeled containers.
Whenever possible, avoid sound-alike and look-alike drug or different
strengths of the same drug being stored side by side.
 Use TALL-man lettering to emphasize differences in medication name
(eg: DOPamine and DOBUTamine)
STRATEGIES TO AVOID ERRORS INVOLVING
HIGH ALERT MEDICATION

7. EXAMPLE:EXAMPLES

8. THIS EXAMPLE ALSO CAN BE
CATEGORISED AS HIGH ALERT
MEDICATION!!!

9. CON’T:
Do not use abbreviations when prescribing High Alert
Medications
Specify the dose, route, and rate of infusion for High
Alert Medications prescribed (eg: IV Dopamine
5mcg/kg/min over 1 minutes)
Prescribe oral liquid medications with the dose
specified in miligrams
Do not use trailing zero when prescribing (eg: 5.0mg
can be mistaken as 50mg)
STRATEGIES TO AVOID ERRORS INVOLVING
HIGH ALERT MEDICATION

10. CON’T:
 The following particulars shall be independently counter checked
against the prescription or medication chart at the bedside by two
appropriate persons before administration:
 Patient’s name and RN
 Name and strength of medication
 Dose
 Route and rate
 Expiry date
 Return all unused medication to pharmacy when no longer
required
 Avoid ordering High Alert Medications verbally. In cases of
emergency, phone orders have to be repeated and verified
STRATEGIES TO AVOID ERRORS INVOLVING
HIGH ALERT MEDICATION

11. CON’T:
Closely monitor vital signs, laboratory data,
patient’s response before and after
administration of medication
Keep antidotes and resuscitation equipment
in wards
STRATEGIES TO AVOID ERRORS INVOLVING
HIGH ALERT MEDICATION

12. CON’T:
All personal shall be trained prior to handling
of High Alert Medication and documentation
kept.
Staff must be trained to prevent potential
errors and enable them to response promptly
when mistakes do occur
STRATEGIES TO AVOID ERRORS INVOLVING
HIGH ALERT MEDICATION

13. CON’T:
References or dilution guide should be made
available in the wards
Monitor adverse drug reaction and
medication errors related to High Alert
Medications
STRATEGIES TO AVOID ERRORS INVOLVING
HIGH ALERT MEDICATION

15. Strength/unit 100 units/ml (1000 units/vial)
Diluents for
infusion
NS
Method of
administration
1) Slow IV bolus: administer undiluted solution over 3-5 minutes
2) Continuous IV infusion: dilute 50 units insulin in 50 ml NS ( 1
units/ml)
Remarks Monitor sign and symptoms of hypoglycemia
If hypoglycemia occurs, stop infusion. For conscious patient, give
sweetened drink. For unconscious patient, administer D50% or glucagon.
Check blood glucose after 15 minutes
MAY CAUSE NEUROHYPOGLYCEMIA AND CAN BE FATAL
Overlap with IV infusion for 1 hour with SC insulin (when converting IV
infusion to SC insulin)

16. Strength/unit 10% W/V, 10mL
Diluents for
infusion
NS
Max recommended concentration (peripheral line): 80mmol/L or 6g/L
Max recommended concentration (central line): 150mmol/L or 11g/L
Method of
correcting
hypokalemia
1) Normal, slow and safe correction of hypokalemia in open wards
1g KCl should be diluted in 500ml NS and transfused over 2-3 hours in a
peripheral line. (infusion rate not exceeeding 20mmol/hr)
2) Rapid correction of hypokalemia
1g KCl should be diluted in the desired concentration of NS in an infusion
pump through central line at rate of 1 hour or less under continuous
ECG monitoring (in an ICU setting)
Remarks Caution in pt with cardiac disease
Do not administer undiluted or iv push
1g KCL = 13.4mEq KCl

17. Strength/unit 0.5mg/2ml
Diluents for
infusion
NS
D5%
Method of
administration
1) Dilution: dilute 0.5mg (1 ampoule) in 50ml for IV infusion
2) Slow infusion is preferred over bolus administration (at least 5
minutes or longer)
3) IV infusion should be given over 10-20 minutes
Remarks Arrhytmias may be precipitated by digoxin toxicity. So, monitoring of
HR is necessary before, during, and after digoxin administration
IM route is not recommended  due to painful and a/w muscle
necrosis
Rapid injection is not recommended as it may cause systemic and
coronary arteriolar constriction
Digitalized patient with hypoalcemia should be given IV calcium slowly
and in a small amount to avoid serious arrythmias

18. Strength/unit 25,000iu/5ml
Diluents for
infusion
NS
Method of
administration
1) Dilution: 1 vial diluted with 50ml
2) CONVERSION FROM IU/HOUR TO ML/HOUR
 BY DIVIDING WITH 500IU
 Eg: from 700IU/hour  1.4ml/hour
MODERATELY HIGH DOSE CAN CAUSE EXCESSIVE INTERNAL BLEEDING
THAT MAY LEAD TO PARALYZING OR LETHAL STROKES

19. REFERENCES
• Dilution Guide for High Alert Medications,
Pharmaceutical Services Division
• Guideline On Safe Use of High Alert
Medication
• Injectable Drugs Dilution 2010

20. Thank You
MEDICATION SAFETY IS EVERYONE’S
RESPONSIBILITY!
yatiazmir@pharmacy2013
yatiazmir@pharmacy2013