22/08/2019
medication # NABH risk drug
COMMON NON CONFORMITY IN SAFE MEDICATION PRACTICES BY HCO
High-risk medications have a hightened risk or cause significant patient harm and/or sentinel events when they are used in error and, as a result, require special safeguards. These medications have narrow therapeutic indexes or small margins of safety; that is, there is a small difference between a therapeutic dose and a harmful dose.
Look-alike/sound-alike (LASA) medications are those, either written or spoken, which may lead to potentially harmful errors when confused with each other.
In my work as a NABH assessor , I realized that there is much confusion in health care organizations about “High –risk medications ” and “Look-Alike, Sound-Alike” medications (LASA) and how to comply with these objective element of NABH standards. So, I offer my suggestions to address this important medication management issue.
Three relevant objective elements & standards are listed below with some compliance suggestions:
MOM 4 j : The organisation defines a list of high-risk medication(s).
MOM5 f : High-risk medication orders are verified prior to dispensing.
MOM 3d : Look-alike and Sound-alike medications are identified and stored physically apart from each other.
Suggestions:
1.Health care organization should develop its own list based on unique utilization and international guidelines (NIOSH,ISMP), and collaborate with clinical pharmacist to help develop the list
2 .Health care organisation should ensure physically separating medicines with LASA names in all storage areas; including both the brand name and nonproprietary name on medication orders toprovide redundancy; and using “tall man” (mixed case) lettering(e.g. DOPamine versus DoBUTamine) to emphasize drug name differences. It is also recommended that he nonproprietary name in proximity to and in larger font size than the brand name.
3.Health care organization should apply this policy to sample medications, if utilized within your organization.
4.Health care organization should Keep lists available in all areas of organization where medications on y high-risk medication and LASA medication lists are administered such as:
Wards
crash carts
automated dispensers
dental carts
bulk storage medication cabinets
narcotic lockers
anesthesia carts
anesthesia work rooms
treatment rooms
immunization rooms
It’s also essential to account for these areas mentioned above when developing your high-risk medication and LASA medication lists and implementing designed process or strategy to prevent errors.
5.Health care organisation should ensure that all staff who administer medications are aware of the organization’s lists, policies, and processes (strategies) to prevent errors when administrating medications that are on high –risk medications and LASA medication lists. These staff include:Physicians
Pharmacist,Nursing staffs,GDA
6.Health care organization should provide training regarding what the staff should do after seeing a medication on your identified lists.
Conclusion :
If health care organization want to provide a zero-harm experience with medication administration and it is essential that all stakeholders or relevant staffs are aware of the risks with high-risk and LASA medications.
References :
1.http://www.ismp.org/tools/institutionalhighAlert.asp
2. Institute for Healthcare Improvement (IHI). (2012). How-to Guide: Prevent Harm from High-Alert Medications. Cambridge, MA: Institute for Healthcare Improvement; Retrieved from www.ihi.org.
3. McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safetycheck. Joint Commission Journal on Quality and Patient Safety, 2005, 31(1):47–53.
4. Look-alike and sound-alike drug names—a step forward. Hospital News, January 2004. http://ismpcanada.org/download/HNews0401.pdf.
