High risk medicines Draft

Written by grixtik on . Posted in Development

High risk medicines are those that have a higher risk of causing severe injury or harm if they are misused or used in error.

Several standardised clinical forms, guidelines and decision support materials have been developed to minimise the risks associated with the use of these medicines.

APINCH is an acronym used to describe high risk medicines.

Additional information is available by clicking below.

A – Anti-infectives

Aminoglycosides

There are risks associated with antimicrobials such as aminoglycosides, vancomycin and amphotericin due to their toxicity, particularly if dosed incorrectly.

A state-wide Aminoglycoside Dosing in Adults Guideline [PDF] exists to support the safe use of aminoglycosides.

Vancomycin

Refer to local Pharmacy departments for procedures or guidance on vancomycin dosing.

Amphotericin

There are risks of confusion with non-lipid and lipid formulations of amphotericin.  Refer to local Pharmacy departments for procedures or guidance relating to intravenous amphotericin use.

Antibiotic re-exposure

Another risk associated with anti-infective use is exposure to medicines patients have had a documented adverse drug reaction.  All patients should have their adverse drug reaction (ADR) and allergy status documented by a clinician as soon as possible after presentation to hospital and prior to prescribing or administering a medicine.

Documentation of a previous ADR or allergy includes:

  • The medicine (or substance).
  • Reaction details (e.g. rash, diarrhoea) and type (e.g. allergy, anaphylaxis).
  • Date that it occurred or approximate time frame (e.g. 20 years ago).
  • Place a yellow ‘Adverse Drug Reaction’ sticker.

P – Potassium and other electrolytes

Critical incidents have been associated with the preparation and administration of intravenous (IV) potassium chloride.  Hence, potassium ampoules have been removed from ward areas and replaced with premixed solutions.  Consult your pharmacy department for available premixed products.

Decision support available for prescribing of fluids, potassium and other electrolytes includes:

I – Insulin

Two standardised state-wide insulin order and blood glucose record forms exist:

These forms provide decision support for initiation of insulin, management of hyperglycemia and hypoglycaemia.

Safe insulin prescribing tips:

  • Prescribe insulin using complete brand name (e.g. Humulin NPH, Lantus)
  • Alert your pharmacist or diabetes educator if a patient is admitted on a high concentration insulin (e.g. Toujeo, Humulin R U-500)

More information regarding high concentration insulin is located in the QH Patient Safety Communique.

N – Narcotics and other sedatives

Multiple standardised state-wide forms are available for prescribing opioids. 

These include:

Safe narcotic (opioid) prescribing tips:

  • It is generally acceptable to prescribe oral formulations using brand name – it will help nursing staff identify the correct opioid with the correct release profile. E.g. Oxycontin, Endone etc.
  • Consider the amount of opioid used during hospital stay and what may be appropriate discharge doses and supply quantities.
  • These medications have been associated with adverse drug events due to inappropriate prescribing, lack of patient monitoring, insufficient staff support, and medication administration errors, particularly when being given via the intravenous (IV) route. Refer to any local procedures.

C – Chemotherapeutic agents

Some best practice recommendations related to chemotherapeutic agents include: 1

  • Prescribers include the mg/m2 dose or area under the curve dose or mg/kg dose with all chemotherapy drug orders.

  • A pharmacist verifies that the intended dosing regimen and prescriber’s calculated dose listed with a chemotherapy order is correct, and they document a double check of the prescriber's calculated dose before preparing and dispensing the medicine.

  • Nursing staff permanently documents an independent double check of the prescriber's calculated dose for chemotherapy before administering the medicine.
  • When prescribing once weekly or intermittent medication administration (e.g. weekly methotrexate), the prescriber clearly identifies the day of administration on the medication order and places an X in other boxes to prevent against daily dosing.

H – Heparin and anticoagulants

A state-wide Heparin Intravenous Infusion Order and Administration Form [PDF] exists for prescribing intravenous heparin.  Decision support is available on the back side of the form and on the flowchart for Adjusting Heparin Intravenous Infusions When APTT More Than 200 Seconds for Medical Officers [PDF].

Each patient should have their venous thromboembolism (VTE) risk assessed and documented on the NIMC VTE Prophylaxis Section [PDF]. Refer to local guidelines for assistance with VTE risk assessment.

Warfarin should be prescribed on the warfarin section of the NIMC.  Decision support is available in the Guidelines for Anticoagulation using Warfarin – Adult [PDF].

There are multiple state-wide guidelines relating to anticoagulants.  These include:

Note to learners

All linked PDFs  in the above interaction were downloaded on 1 May 2018 and may no longer be current.

Direct links to all documents from this page are provided below, please note that many are located on the QHEPS network and are not accessible from a non QLD Health connect device.

Direct links to PDF's

Please note that some of these links are located on the QHEPS network and are not accessible on a non QLD Health connected device.

A – Anti-infectives

P – Potassium and other electrolytes

I – Insulin

N – Narcotics and other sedatives

H – Heparin and anticoagulants

References

1.Medication Safety Self Assessment® for Australian Hospitals (2015), Clinical Excellence Commission, 2015. Sydney: Clinical Excellence Commission

2.American Pharmacists Association. Medication Errors. 2nd ed. Washington DC American Pharmacists Association 2007.