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New Jersey News: Storage and Dispensing of High-Alert Medications
Reprinted from the October 2008 New Jersey Board of Pharmacy Newsletter.
The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”
A medication error involving a high-alert medication can have tragic consequences. The erroneous dispensing of methotrexate 2.5 mg for minoxidil 2.5 mg, and Purinethol® 50 mg for propylthiouracil 50 mg are just two examples of medication errors associated with patient fatalities that have occurred in New Jersey. The Institute for Safe Medication Practices (ISMP) publishes a list of high-alert medications, which are defined as “drugs that bear a heightened risk of causing significant patient harm when they are used in error.” Examples include intravenous (IV) adrenergic agonists such as epinephrine, IV adrenergic antagonists such as propranolol, antithrombotic agents such as warfarin, chemotherapeutic agents, oral hypoglycemic agents, and total parenteral nutrition solutions. ISMP recommends additional safeguards to minimize the risk of selecting the wrong medication when filling and dispensing a prescription for a high-alert medication. These safeguards may include improving pharmacist access to drug information, storing high-alert medications in such a way as to limit access to them, using auxiliary labels and automated alerts, and employing a standardized process for ordering, storage, and dispensing. In addition, ISMP recommends the use of manual redundancies such as independent double-checks when these medications are dispensed. Licensees are encouraged to review the ISMP list of high-alert medications and recommendations for preventing medication errors. The ISMP Web site is located at www.ismp.org.
