Medication Safety Alerts

Currently the Commission provides two national medication safety alerts.

1. National high risk medication alert - Vincristine


2. National high risk medication alert - Intravenous Potassium Chloride

Medication safety alerts are issued in response to reported incidents or for medicines with known high risks. High risk medicines include:

• Medicines with a low therapeutic index; and


• Medicines that present a high risk when administered by the wrong route or when other systems error occur. Medication safety alerts advise action to prevent future adverse medicine events or to lessen the risk of such events.

The aim of alerts is to:

• Warn healthcare professionals about serious known medication risks;


• Outline the action required to minimise risks;


• Provide tools to minimise risk.

The Australian Commission on Safety and Quality in Health Care makes available a range of medication safety alerts and guidance issued by itself, by Australian States and Territories and by international medication safety organisations.

Safety alerts and other guidance are classified according to the following taxonomy:

P Potassium
I Insulin
N Narcotics
C Chemotherapy
H Heparin
S Systems

To encourage practice monitoring and improvement, each high risk drug class is mapped to tools validated in Australia. The tools are Medication Safety Self Assessment for Australian Hospitals and Indicators for Quality Use of Medicines in Australian Hospitals.

General principles for best practice in management of all high risk drugs, and relevant links to validated tools, are provided further down the page.

Acknowledgement - The Commission thanks the Victorian Medicines Advisory Committee on High Risk Medicines for allowing it to use the work developed for its high risk medicines web page. The Commission also thanks NSW Therapeutic Advisory Group (Mr David Maxwell and Dr Jocelyen Lowinger) and NSW Clinical Excellence Commission (Mr Daniel Lawlor) for their work mapping high risk drug practice into the MSSA and QUM Indicators tools.

High risk medicines

Potassium and other electolytes

Electrolyte availability
MSSA 5.27: Vials of concentrated forms of electrolytes (eg., potassium chloride, potassium phosphate, magnesium sulfate, and sodium chloride greater than 0.9%) that require dilution before IV use are not available as ward or imprest stock and/or in automated dispensing cabinets on any patient care units (including in operating room/anaesthesia stock).

Potassium availability
QUM indicator 6.1: Percentage of medication storage areas outside pharmacy where potassium ampoules are available.


1. IV potassium chloride alert - Australian Commission on Safety and Quality in Health Care


2. Guideline for replacement of potassium - Victorian Therapeutic Advisory Group (PDF 71 KB)


3. Policy for use of IV potassium chloride - WA Department of Health


4. IV administration of mis-selected concentrated potassium chloride - UK National Patient Safety Agency


5. Potassium chloride update - UK National Patient Safety Agency


6. Safety strategies for potassium phosphates injection - ISMP Canada (PDF 280 KB)

Insulin

Sliding scale insulin
MSSA 5.7: Sliding scale regular subcutaneous insulin is not used to treat elevated blood glucose levels in diabetic patients. OR A standardised sliding scale protocol is used to treat elevated blood glucose levels in diabetic patients. Exception: The protocol may allow for several choices depending on specific patient conditions such as diagnosis/weight/total amount of daily insulin, but the choices are standardised among different prescribers.


1. Insulin alert - Victorian Department of Human Services (PDF 50 KB)


2. Sub-cutaneous insulin audit tool - Victorian Department of Human Services (PDF 63 KB)


3. Insulin errors - ISMP Canada (PDF 158 KB)

Narcotics and sedatives

Sedation antidotes
MSSA 5.13: Antidotes for MODERATE SEDATION and PCA/other IV infusion to treat pain and accompanying guidelines for emergency use are readily available near the point of use.

Neuromuscular blocking agent availability
MSSA 5.24: Neuromuscular blocking agents are not available as ward or imprest stock and/or in automated dispensing cabinets (except in operating room/anesthesia stock). OR If available in critical care units and/or the ED, neuromuscular blocking agents are sequestered from other ward or imprest stock medications (including those stocked in automated dispensing cabinets) and labelled with auxiliary warnings to clearly identify the drugs as respiratory paralysing agents that require mechanical ventilation when used.

PCA pumps
MSSA 6.8: The types of patient controlled analgesia (PCA) pumps used in the hospital are limited to two or less to maximise competence with their use.

Documentation pain intensity
QUM indicator 4.1: Percentage of postoperative patients whose pain intensity is documented using an appropriate validated assessment tool

Written pain management plan
QUM indicator 4.2: Percentage of postoperative patients that are given a written pain management plan at discharge and a copy is communicated to the primary care clinician

Sedatives at discharge
QUM indicator 5.7: Percentage of patients receiving sedatives at discharge that were not taking them at admission


1. Oxycodone - NSW Health (PDF 443 KB)


2. Fentanyl skin patches - NSW Therapeutic Advisory Group (PDF 154 KB)


3. Fentanyl skin patches - US Institute for Safe Medication Practices


4. Fentanyl skin patches - ISMP Canada (PDF 246 KB)


5. Risks with high dose morphine and diamorphine injections - UK National Patient Safety Agency

Chemotherapeutic agents

Dose calculation
MSSA 10.32: Prescribers include the mg/m2 dose or area under the curve dose or mg/kg dose with all chemotherapy drug orders. Parameters are periodically reviewed (on at least a weekly basis) for prolonged hospital admissions, as current weight/Body Surface Area (BSA) may differ from admission measurements.

Dose calculation - pharmacist independent verification
MSSA 10.34: A pharmacist verifies that the mg/m2 dose, or area under the curve dose, listed with a chemotherapy order is correct, and documents (eg. with initials) a double check of the prescriber's calculated dose (or it is performed electronically) before preparing and dispensing the drug.

Dose calculation- nurse independent double check
MSSA 10.36: Nurses permanently document (e.g., with initials) an INDEPENDENT DOUBLE CHECK of the prescriber's calculated dose for chemotherapy before administering the drug.

Drug independent double check
MSSA 10.38: The drugs, actual drug containers, doses, diluents, and volumes added to the diluent for chemotherapy admixtures or compounded oral solutions are INDEPENDENTLY DOUBLE CHECKED by a pharmacist or a nurse (even if initially prepared by a pharmacist) and documented (e.g., with initials) before dispensing/administering the products.

Protocol based chemotherapy
QUM indicator 3.6: Percentage of patients receiving cytotoxic chemotherapy whose treatment is guided by a hospital approved chemotherapy treatment protocol


1. Vincristine - Australian Commission on Safety and Quality


2. Vincristine audit alert - Victorian Medicines Advisory Committee (PDF 177 KB)


3. Safe Administration of Vinca Alkaloid Drugs - WA Department of Health


4. Safe use of oral methotrexate - NSW Health (PDF 50 KB)


5. Methotrexate - Victoria Therapeutic Advisory Group (PDF 41 KB)


6. Methotrexate - UK National Patient Safety Agency


7. Methotrexate - Improving compliance with guidelines - UK National Patient Safety Agency


8. Methotrexate - ISMP Canada (PDF 242 KB)


9. Fluorouracil - ISMP Canada (PDF 254 KB)





Heparin (and other anti-coagulants)

Medication Safety Self Assessment for Antithrombotic Therapy in Australian Hospitals


1. Warfarin - NSW Health (PDF 246 KB)


2. Unfractionated Heparin - Victorian DHS (PDF 91 KB)


3. Unfractionated Heparin audit tool - Victoria DHS (PDF 82 KB)


4. Unfractionated Heparin - ISMP Canada (PDF 287 KB)


5. Heparin-induced thrombocytopenia - ISMP Canada (PDF 81 KB)


6. Making anticoagulant therapy safer - UK National Patient Safety Agency


7. Appropriate anti-coagulant use - ISMP Canada (PDF 350 KB)





Systems

1. Safer lithium therapy - UK National Patient Safety Agency December 2009


2. Wrong route administration of oral medicines - Victorian DHS (PDF 61 KB)


3. Wrong route administration of oral medicines audit tool - Victorian DHS (PDF 102 KB)


4. Safer measurement and administration of liquid medicines via oral and other enteral routes - UK National Patient Safety Agency


5. Independent double checks for patient controlled analgesia - ISMP Canada (PDF 90 KB)


6. High alert drugs and infusion pumps: Extra precautions required - ISMP Canada (PDF 56 KB)

Updated: 09 December, 2009

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