To evaluate the impact of a high-alert medication clinical decision support system called HARMLESS on point-of-order entry errors in a tertiary hospital.
Review of prescribing errors indicated that most errors were associated with narcotics—an Institute for Safe Medication Practices-defined high-alert medication.
Insulin has consistently been designated as a high-alert medication because of the risk of harm that can accompany errorsin prescribing, transcribing, or dosing (136).
In each ward, a standard label of high-alert medication should be pasted to the place where insulin/insulin analog are stored.
The significantly higher rate of oxytocin use among women admitted in pre-active labor is concerning because oxytocin, a "high-alert medication" [ 41], is the intervention most commonly associated with preventable adverse perinatal outcomes [ 42].
If inappropriately administered, IVPR can lead to arrhythmias, cardiac arrest and death. 2 7 8 Given these risks, IVPR is considered a 'high-alert medication' by the Institute of Safe Medication practice.
Examples of CDSS are electronic reminders, alerts, medication pick-lists, formularies, dose calculators, medication regime management suggestions or guideline presentation.
High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered.
Six high-alert medications and associated adverse events were selected for inclusion in the Medicare Patient Safety Monitoring System (MPSMS), a national surveillance system designed to identify and track over time inpatient adverse events within the hospitalized fee-for-service Medicare population.
To determine whether sociotechnical probabilistic risk assessment can create accurate approximations of detailed risk models that describe error pathways, estimate the incidence of preventable adverse drug events (PADEs) with high-alert medications, rank the effectiveness of interventions, and provide a more informative picture of risk in the community pharmacy setting than is available currently.
