High alert medications (HAM) Lecture presented in the unit of clinical pharmacy, Al-Mahmoudiya General Hospital As part of the training course for clinical pharmacy 22/5/2023

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High - Alert
Medications
Alaa Fadhel Hassan(MSc. Pharm)
Drug Information Centre
Al-Mahmoudiya general hospital

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High alert medications (HAM)
 Defined as the medications which can cause significant
medical harm when used in error, i.e. errors whether
common or few with such medications, they are expected to
have more devastating consequences to the patients
 They must be double checked before administration by two
licensed healthcare professions (authorized to administer/or
dispense medications).
 Main principles that affect HAM’s safe use:
 Patients and the public
 Healthcare professionals
 Medicines
 System and practices of medications

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The Strategic framework of Global
Patient Safety Challenge

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Institute for Safe Medication
Practices (ISMP) High Alert
Medications - Classes/ Categories
of Medications

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ISMP Classes /Categories of Medications
adrenergic agonists, IV (e.g., epinephrine, phenylephrine,
norepinephrine)
adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)
anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)
antiarrhythmics, IV (e.g., lidocaine, amiodarone)
antithrombotic agents, including:
anticoagulants (e.g., warfarin, low molecular weight heparin,
unfractionated
heparin)
direct oral anticoagulants and factor Xa inhibitors (e.g., dabigatran,
rivaroxaban,
apixaban, edoxaban, betrixaban, fondaparinux)
direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran)
glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)
thrombolytics (e.g., alteplase, reteplase, tenecteplase)
cardioplegic solutions

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ISMP Classes /Categories of Medications
chemotherapeutic agents, parenteral and oral
dextrose, hypertonic, 20% or greater
dialysis solutions, peritoneal and hemodialysis
epidural and intrathecal medications
inotropic medications, IV (e.g., digoxin, milrinone)
insulin, subcutaneous and IV
liposomal forms of drugs (e.g., liposomal amphotericin B) and
conventional counterparts (e.g., amphotericin B desoxycholate)
moderate sedation agents, IV (e.g., dexmedetomidine, midazolam,
lorazepam)
moderate and minimal sedation agents, oral, for children (e.g., chloral
hydrate, midazolam, ketamine –the parenteral form)

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ISMP Classes /Categories of Medications
opioids, including:
IV, transdermal
oral (including liquid concentrates, immediate- and sustained-release
formulations)
neuromuscular blocking agents (e.g., succinylcholine, rocuronium,
vecuronium)
parenteral nutrition preparations
sodium chloride for injection, hypertonic, greater than 0.9%
concentration
sterile water for injection, inhalation and irrigation (excluding pour
bottles) in containers of 100 mL or more
sulfonylurea hypoglycemics, oral (e.g., chlorpropamide, glimepiride,
glyburide, glipizide, tolbutamide)

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ISMP Specific Medications
 epinephrine,
subcutaneous
 Epoprostenol, IV
 insulin U-500
 magnesium sulfate
injection
 methotrexate, oral,
nononcologic use
 nitroprusside sodium for
injection
 opium tincture
 oxytocin, IV
 potassium chloride for
injection concentrate
 potassium phosphates
injection
 promethazine injection
 vasopressin, IV and
intraosseous

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Common risk factors associated with
HAM

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What to do for safe handling of HAM
 Procurement (limit available medication strength, avoid frequent
changes of brands & colours)
 Storage (use cautionary labels “High alert medication” on both
medication package; that don’t cover medications details, and
storage shelves‘, avoid storing with Look-alike & Sound alike
medications “LASA”, label different strength of the stocked
medication, & finally use TALL-man lettering to emphasize
differences of medication names (eg. DOPamine and
DOBUTamine).
 Prescribing (use standard forms for written orders of cytotoxic
medications and parenteral nutrition, avoid abbreviation, specify
clear dose, route and rate of infusions, prescribe oral liquid
medications with the specific dose in mg, write leading zero with
decimal doses, use generic names, state the body weight and
surface area for chemotherapy &/ special pt. like paediatric, avoid
HAM verbal medication order unless emergencies exist &
document them as soon as possible)

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What to do for safe handling of HAM
 Preparations (establish checking order for all HAM
preparations, HAM calculations to be checked includes
cytotoxic medications, parenteral nutrition &
extemporaneous preparations, label All diluted medications
with the name and strength immediately upon dilution)
Ex. Our hospital recommended labels for parenteral
preparations

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What to do for safe handling of HAM
 Administration (estimate double checking order by 2
qualified healthcare professions of prescribed medication
chart at the bedside for all details of management including
pt. identifiers, medication & administrations full details,
expiry date, parenteral lines attachments, return all unused
or remaining preparations to the pharmacy, ensure
administration of intrathecal, cytotoxic medications, epidural
analgesics and parenteral nutrition is carried out by trained
healthcare professions)
 Monitoring (monitor and document pt. vital signs,
laboratory data, response before and after administration of
HAM, prepare antidotes and resuscitation equipment in
wards/emergency room/units, intensive care units).

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What to do for safe handling of HAM
 Documentation (check any unclear or inaccurate
documentation prior to dispensing or administering &
complete all medication record documentation)
 Medication Information (prepare an easily accessed &
accurate List of high alert medications to all healthcare
professions, prepare updated medication references or
dilution guide, monitor and report all adverse drug reactions
and medication errors related to HAM)
 Healthcare Professions Training (All healthcare
professions should be trained for safe handling of HAM &
emphasize the importance of accurate checking to
prevent/& and respond promptly to potential medical errors)

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What to do for safe handling of HAM
 Patient education
always educate pt. and family members/caregivers on:
(the 5 Rights(5R) - Know Your Right patient to be given the
Right medication in the Right dose, the Right route & for the
Right time, inform them about common side effects/potential
adverse reactions & finally inform them to adhere to specified
medication regimen)

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References
 The Institute for Safe Medication Practices (ISMP) Recommendations.
https://www.ismp.org/resources?field_resource_type_target_id[13]=13#
resources--resources_list
 Institute for Safe Medication Practices. ISMP List of High-Alert
Medications in Acute Care Setting, 2018
https://www.ismp.org/sites/default/files/attachments/2018-
08/highAlert2018-Acute-Final.pdf
 Pharmacy Service, UNM Hospitals. High Alert, and Look-Alike Sound-
Alike Medications. Aug. 2018
 Medication Safety Section, Pharmacy Practice and Development
Division, Pharmaceutical Services Programme, Ministry of Health
Malaysia. GUIDELINE ON SAFE USE OF HIGH ALERT
MEDICATIONS (HAMs). 2nd Edition Nov. 2020
https://www.pharmacy.gov.my/v2/sites/default/files/document-
upload/guideline-safe-use-high-alert-medications-hams-2nd-
edition_1.pdf

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THANK YOU