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Pharmacy Practice Manual John Dempsey Hospital-Department of Pharmacy University of Connecticut Health Center High Alert Medications

POLICY: The Pharmacy and Therapeutics Committee, with the input of the Medication Safety Committee, has reviewed the hospital's formulary and trend analysis of medication errors to determine a list of High-Risk/High Alert medications. Additional input is incorporated from such organizations as the Institute for Safe Medications Practices (ISMP), United States Pharmacopoeia (USP) and other national databases reporting information on the use of medications. The primary objective is to provide the highest quality pharmaceutical care with the minimum number of medication errors and the lowest potential for patient risk. PURPOSE: High-Alert medications are drugs that have a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. High Alert meds have a higher risk of causing injury, either as a result of a narrow therapeutic range or due to a high incidence of reported serious errors. Methods to reduce error include strategies such as improving access to information about these drugs; limiting access to High-Alert medications; using Tallman lettering, using auxiliary labels and automated alerts; standardizing the ordering, storage, preparation, and administration of these products; and employing redundancies such as automated or independent double checks when necessary. New formulary medications and additional relevant safety information will be reviewed for inclusion on the High-Alert Medication list by the Pharmacy and Therapeutics committee. Medications that the Medication Safety Committee and the Pharmacy and Therapeutics Committee (P&T) has deemed to be High Risk or High-Alert include the following: High Alert Medication List: A. Chemotherapy agents B. Heparin infusions C. Argatroban Infusions D. Insulin ­ both continuous infusions and subcutaneous doses E. Narcotics ­ Continuous infusions, Epidural narcotic infusions, PCA, and F. Any Medication infused on an Epidural Pump including interscalene or regional nerve blocks G. Epoprostenol (Flolan)-IV & Treprostinil (Remodulin)- IV/SC H. Fentanyl Patches I. Continuous Thrombolytics Infusions- alteplase (TPA=Activase)

PROCEDURE: Prescribing: 1. The electronic ordering system will be periodically updated to reflect standards of care, doses and concentrations approved by the Pharmacy & Therapeutics Committee and information needed to optimize patient safety. 2. Chemotherapy Orders must be written on Chemotherapy Order forms and signed by an attending Physician and include the patient's allergies, height, weight in kilograms, and body surface area. This allows the nurse and pharmacist to double-check calculations based on BSA and weight.

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Preparation and Dispensing: 1. Safety procedures will be employed in the ordering, preparation, dispensing and administration of High-Alert Medications. 2. Guidelines for the use of these medications are included in the IV Guidelines listed online under Medication References. These guidelines are periodically updated to reflect standards of care. 3. Concentrated vials of potassium chloride, potassium phosphate, magnesium sulfate and calcium gluconate will only be stored separately in the Department of Pharmacy. Standarized diluted solutions of these electrolytes are located in Pyxis machines on nursing units. The only exception is that NICU has restricted access in Pyxis for stocked Concentrated vials of magnesium sulfate and calcium gluconate. Special labeling is required to ensure dilution before use. Administration: 1. A double check must be performed prior to administration of any of the following medications (refer to the Nursing Practice Manual Policy `Medications: High Alert, Double Check of' to review the steps required in a double check): A. Any chemotherapy infusion, B. Heparin- continuous infusions C. Argatroban - continuous infusions D. Insulin -continuous IV infusions and subcutaneous doses E. Narcotic infusions, including continuous infusions, PCA's, and epidural narcotic infusions F. Any Medication infused on an Epidural Pump including interscalene or regional nerve blocks G. Epoprostenol (Flolan)-IV & Treprostinil (Remodulin)- IV/SC H. Fentanyl Patches i. A double check is required for disposal of used Fentanyl patches only. I. Continuous Thrombolytics Infusions- alteplase (TPA=Activase)

2. All high risk continuous medications must be administered with IV pumps utilizing the drug library. a. Flolan and Remodulin are two infusions that may be administered on a patients home ambulatory pump that does not have a drug library. These infusions also require a double check of the rate of delivery by two RNs. A. *Chemotherapy Add link to Chemo Policy 1. Chemotherapy Orders must be written on the Chemotherapy Order form and signed by an attending Physician. 2. No verbal orders for chemotherapy are allowed. 3. Chemotherapy will be administered based on the patient's orders and according to the procedures outlined in general accepted standards of practice. 4. All chemotherapy prepared by a Pharmacy Technician will be double-checked by 2 pharmacists. 5. The following Sticker will be placed on each patient specific item of chemotherapy: "Caution: Anti-Neoplastic material " Handle Properly." 6. Chemotherapy will be double-bagged to minimize the potential for spread of spills.

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B. Heparin CI's 1. Store different concentration vials separately. 2. Standardized Infusion of Heparin 25,000 units/ 500 mls D5W= 50 units/ml 3. Standardized Dosing Nomograms & Orders are in place for 1. DVT/PE, 2. Cardiac, Vascular, Stroke 3. Ultra-filtration 4. Dosing Nomograms for 1. DVT/PE 2. Cardiology, Vascular , Acute Ischemic Stroke, are barcoded forms. The appropriate nomogram that matches the POE order must be placed in the patient's chart. These nomograms are available for reference only on the Nursing Website under Medication References.

C. Argatroban for Heparin Induced Thrombocytopenia (HIT)

1. 2. 3. Policy and Procedure listed in the Medication References Standardized Infusion of Argatroban 250mg / 250 mls NS = 1mg/ml Use of drug library on infusion pump

D.Insulin 1. Insulin Infusions: Standard concentration = 1unit/ml, High Alert Sticker a. Standarized protocol for ICU insulin infusions 2. Insulin vials opened on nursing units will have an expiration date of 28 days. 3. Insulin vials are separated by type in labeled bin dividers in the refrigerators E. Narcotic infusions, including PCA & epidural narcotic infusions 1. Opiates and all other controlled substances shall be maintained under locked storage in the Pharmacy Department and patient care units. 2. High Alert Sticker: for non-standard concentration continuous infusions that are hand delivered to units at time of need. 3. All are standardized by equipotent concentrations: Standard concentrations: Morphine 1mg/ml, Hydromorphone (Dilaudid) 0.2 mg/ml, Fentanyl (ICU use) 10 mcg/ml . High concentrations: Morphine 5mg/ml, Hydromorphone (Dilaudid) 1 mg/ml, Fentanyl (ICU use) 50 mcg/ml . 4. High Concentrations of Hydromorphone (Dilaudid) 1 mg / 1 ml as PCA syringes or Infusions will be either hand delivered by the unit pharmacist or stored in a separate locked narcotic box in Pyxis or the medication refrigerator specifically labeled on the outside and on the solution as HIGH ALERT & HIGH CONCENTRATION. 5. Orders for Narcotic CI's must follow the Titrating Orders Policy & Titration Guidelines For IV Medications Chart that are available on-line under Medication References. They can be ordered as "Adjust" as clinically appropriate or "Do Not Adjust". Call MD/LIP for dose changes as needed. 6. Labeling to show High Concentration" to differentiate from standard concentrations. 7. Fentanyl Continuous IV Infusions A. ICU- Standard concentration of 10 mcg/ml, infused with Smart Pump safety software with standard concentrations, minimum and maximum amounts of infusion. Requires double check per policy. B. NICU ­ Standard concentratons of 4 mcg/ml and 12.5 mcg/ml, selected based on volume status of newborn, requires double check in pharmacy manufacturing and nurse verification with order, calculations and pump settings. Infused with

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Smart Pump safety software as mcg/kg/hr with standard concentrations, minimum and maximum amounts of infusion. Requires double check per policy. F. Any Medication infused on an Epidural Pump including interscalene or regional nerve Blocks require Epidural sticker to be affixed to the bag. G. Epoprostenol (Flolan)-IV & Treprostinil (Remodulin)- IV/SC Pharmacists must follow the IV Med guidelines and complete the Policy and Procedure Sheets ( found under PAH in the I drive) for both medications when given as IV/SC. H. Fentanyl Transdermal Patches A. MD/LIP Ordering Order screens will list guides for safe and effective prescribing. a. Not for opioid naïve patients, b. Not for short term acute pain. c. For newly prescribed Fentanyl patches, consultation with the unit Pharmacist is strongly encouraged since this delivery system has unique pharmacokinetics, requires prn opioids for breakthrough pain and has special dosing conversions. d. For newly prescribed Fentanyl patches doses should not be increased for pain control until steady state in reached at 3 days. Pharmacist Validation - The unit Pharmacist will review the order per policy to assure that dosing and ordering precautions have been addressed as described above. Any concerns identified during order review will be addressed with the ordering MD/LIP. Nursing: Follow the procedure for Fentanyl patch application, removal, and disposal outlined in the Medication: Double Check of High Alert Policy Patient Education: Patient Education Material on Fentanyl patches is available on the medication references page of the Nursing Website.

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I. Continuous Thrombolytics Infusions - alteplase (TPA=Activase) Pharmacists must follow the IV Med guidelines and admixing instructions per indication. Nursing Procedure: APPROVAL: Nursing Standards Committee & Department of Pharmacy 2/09, 12/09/09 Approval P&T Com: 12/10/09 REVISED: ______________________________________________ Date__________________ Dr. Jeffrey Gross ______________________________________________ Date__________________ Thomas Pizzoferrato, PharmD EFFECTIVE DATE: 3/07 REVISION DATES: 2/09, 12/09/09, 12/7/10, 5/6/11

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