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Pharmacy Times
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Pharmacists can prevent medication errors through knowledge, communication, and education
High-Alert Medications
High-alert medications are those that have a high risk of causing significant injury or harm to the patient when they are misused or used in error. Although mistakes may or may not be more common with these drugs, the sequelae are clearly more devastating to patients.1 Some common characteristics of high-alert medications include a narrow therapeutic index; complex, unusual dosing and/or monitoring requirements; availability in multiple strengths and forms; and look-alike or soundalike naming or packaging to other medications.2
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Acetaminophen
Acetaminophen, an effective and readily available analgesic and antipyretic, is well tolerated in both children and adults. However, acetaminophen may be considered a high-alert medication due to its ability to cause hepatotoxicity in susceptible individuals. This usually occurs in patients taking more than 1 acetaminophen-containing product concurrently and miscalculating dosage based on weight in underweight individuals.3
Chemotherapy Agents
Chemotherapy agents represent a broad range of medications used to treat cancer and some nonmalignant conditions. Traditional chemotherapy agents disrupt the replication process of rapidly dividing cells. Newer chemotherapy agents target specific proteins or pathways involved in the growth of cancers.4
Chemotherapy agents are considered high-risk medications due to complex treatment regimens, narrow therapeutic index, and risk of both acute and delayed toxicities. These adverse outcomes can be the result of errors in calculation, administration rate, infusion device programming, route of administration, or ineffective patient education regarding the management and/or urgency of potential adverse effects.4
Kathleen Kenny, PharmD, RPh, earned her doctoral degree from the University of Colorado Health Sciences Center in Aurora. She has more than 25 years of experience as a community pharmacist and works as a clinical medical writer based in Homosassa, Florida.
Insulin
Insulin is an essential hormone produced by the pancreas and is responsible for regulating blood glucose levels. As a medication, insulin is most often used to treat diabetes. Knowledge about the different types of insulins, their action profiles, and presentations is essential to reduce errors with this high-alert medication.5
Medication errors with insulin can lead to serious patient harm related to hypoglycemia, hyperglycemia, and ketoacidosis. These errors typically occur through incorrect timing of administration, inappropriate withdrawal from pen devices, administering incorrect products with different action profiles, and look-alike or soundalike errors, including high-concentration insulin products.5
Oral Methotrexate
Oral methotrexate is used in the treatment of some autoimmune or inflammatory diseases, although methotrexate may also be used in the treatment of malignancies as part of a specialized protocol. Unlike most medications, methotrexate is dosed once per week as opposed to once per day. This can lead to severe adverse effects when patients administer the medication more frequently than intended.6
Methotrexate toxicity can be dose dependent. In such cases, this may cause nausea, vomiting, diarrhea, myelosuppression, pancytopenia, liver dysfunction, acute renal failure, mucositis, stomatitis, and ulceration of the gastrointestinal system.7
Neuromuscular Blocking Agents
Neuromuscular blocking agents are used for skeletal and respiratory muscle relaxation in patients to facilitate endotracheal intubation and to prevent muscle contraction. These agents are considered high alert due to their potential inadvertent use without skilled airway support staff available and can result in respiratory arrest, permanent harm, or death.8 Contributing factors involved with the inadvertent administration of neuromuscular blocking agents include look-alike packaging, soundalike medications, administration after extubation, and use of unlabeled, preprepared syringes.8
Opioid Analgesics
Opioid analgesics affect the opioid receptors in the central nervous system and gastrointestinal system, causing analgesia, respiratory depression, sedation, and constipation. Prescription of opioids upon hospital discharge deserves special caution because there is risk of dependency, adverse effects, drug interactions, cognitive impairment, and falls.9
Opioids are high-alert medications because the consequences of use are far-reaching. These include dependence, injury, overdose, antisocial behavior, and death. Errors are associated with administration of an incorrect formulation, such as taking a short-acting formulation when a long-acting formulation was intended. Errors can also include failure to adjust dose due to patient factors such as renal function, age, comorbidities, tolerance, and drug interactions. Another factor can be calculation errors including transitioning between opioids, formulations, and routes of administration. Finally, pharmacists should stay vigilant for inappropriate use of patches containing fentanyl and buprenorphine, such as use in opioid-naive patients, applying patches at an incorrect time interval, cutting or partially applying patches, and failure to remove the old patch before applying a new patch.9
Intravenous Potassium
Potassium salts are administered intravenously to treat hypokalemia. Incidents of inadvertent or incorrect administration may result in cardiac arrhythmias and cardiac arrest. This may occur when potassium is administered too rapidly by incorrectly programming or not using a rate-limiting device. Inadvertently administering a bolus of concentrated potassium instead of the intended salt can also cause cardiac arrest. Finally, failure to mix a potassium concentrate that is added to an infusion can result in potassium overdose.9
Prevention of Error
Proactively identifying risks and how they can be minimized is the first step to preventing errors with high-alert medications. Once identified, error-proofing can occur with forced functions and fail-safes. Restricting access to high-alert medications can prove effective, as can educating staff and patients regarding the appropriate use of high-alert medications. Antidotes, reversal agents, and remedial measures must be readily available when an error occurs.10
