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VHA National Center for Patient Safety

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High-Alert Medications

Pills spilling from a container.NCPS is concerned with high-alert medications because these drugs are defined as having a higher likelihood of causing injury if misused. Some high-alert medications also have a high volume of use, increasing the likelihood that a patient might suffer inadvertent harm.

Though medication mishaps with these drugs are no more frequent than other drugs, the consequences can be devastating. NCPS promotes three principles to improve high-alert medication administration and distribution:

Eliminate the Possibility of Error

  • Reduce the number of drugs on a facility’s formulary.
  • Reduce the number of concentrations and volumes.
  • Remove high-alert drugs from critical areas.

Make Errors Visible

  • Have two individuals independently check the product to ensure it is correct, particularly when received in bulk. (In this case, the packaging and labeling could misleadingly look similar to another drug.)
  • Have two individuals independently check equipment settings, as applicable, since some drugs are administered intravenously.

Minimize the Consequence of Errors

  • Minimize the size of vials or ampules in the patient care area to the dose commonly needed.
  • Reduce the total dose of high-alert drugs in continuous IV drip bags.
  • Reduce the concentration of the drugs when possible.

Based on these principles, fostering change in the way high-alert drugs are managed and includes things such as:

  • Encouraging standardized dosing procedures.
  • Carefully screening new products.
  • Creating system redundancies, commonly known as “double checks.” 

The program is based on a systems approach to problem solving that focuses on prevention, not punishment. NCPS uses human factors engineering methods and applies ideas from “high reliability” organizations (such as aviation and nuclear power), to target and eliminate system vulnerabilities.

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