Best Practices for High-alert Medications
Situation: An intensive care patient was admitted for intracranial hemorrhage. The care team ordered a 3% NaCl infusion, but the patient was instead accidentally administered heparin IV. Another patient received heparin in an arterial line during a diagnostic procedure, but was accidentally administered 25,000 units heparin/500 cc (treatment strength) instead of 1,000 units heparin/500 cc (flush strength). Neither patient suffered harm from these medication errors.
Background: High-alert medications have a heightened risk of causing significant harm to individuals when they are used in error, or even when used as intended. One review of an adverse drug reaction database estimated that 50% of all preventable adverse drug events stemmed from one of three high-alert medication categories: overdose of anticoagulants, overdose of opiates, and inappropriate insulin dosing associated with hypoglycemia.1
Assessment: The manufacturer labeling/font on the two IV heparin strengths and the 3% NaCl were very similar, making a visual check less effective. In the ICU case, the care team ordered the 3% NaCl infusion at a rate of 1 mL/hr (very low dose) as workaround to get the medication to the bedside quickly. This caused an under-calculation of delivery needs (automated ORCHID process), which then led to an urgent call to the pharmacy for a special delivery of 3% NaCl and a potentially rushed process. In the procedural case, the premixed IV heparin bags are stored across the room from the Pyxis. This made routine use of bar coded medication administration (BCMA) difficult, and therefore the counts of heparin bags as seen by Pharmacy remotely were inaccurate. Again, this led to an urgent call to the pharmacy for a special delivery of heparin and a potentially rushed process.
Recommendations:
- Harbor-UCLA is working on systems fixes to avoid similar errors including:
- Moving the location of the heparin in the procedural area to be distinct from the other IV fluids, closer to the Pyxis
- Use of visual cues to call Pharmacy for restocking heparin bags well in advance of running out
- Investigating changing our supplier of 3% NaCl or heparin for clearer differences in labeling
- Improved restocking procedures in Pharmacy to avoid having infusions in the wrong bin locations
- Stocking the Pyxis with 3% NaCl in ICUs that commonly care for patients with head trauma
- All sites of care at Harbor-UCLA should perform double-checks when administering high-alert medications.
For more information on systems approach to error analysis, see this Patient Safety Primer on the website for the Agency for Healthcare Research and Quality (AHRQ)
Winterstein AG, Hatton RC, Gonzalez-Rothi R, Johns TE, Segal R. Identifying clinically significant preventable adverse drug events through a hospital’s database of adverse drug reaction reports. Am J Health Syst Pharm. 2002 Sep;59(18):1742-1749.