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High-Alert Medication Safety Self-Assessment for Hospitals and Targeted Risk Reduction Tool Development

High-Alert Medication Safety Self-Assessment for Hospitals and Targeted Risk Reduction Tool Development

Performer: Institute for Safe Medication Practices
Principal Investigator:
Michael R. Cohen, RPh, MS

Project Duration: 9/30/15-9/29/17

Regulatory Science Challenge

High‐alert medications have an increased risk of causing significant patient harm when they are used in error. In addition to insulin, anticoagulants, and opioids, high-alert medications include antiarrhythmics, intrathecal or epidural medications, radiocontrast agents, anesthetic agents, neuromuscular blocking agents and other medications. Strategies to prevent errors associated with high-alert medications have been known for more than a decade, but how well such strategies are implemented in healthcare organizations is unclear. The Institute for Safe Medication Practices (ISMP) believes that a medication safety self-assessment tool can be used to increase the awareness of best practices related to specific high-alert medications. It will also allow interdisciplinary healthcare teams to evaluate their compliance with these best practices and develop customized action plans to improve safety.

Project Description

ISMP plans to develop an assessment tool, which will ask clinicians to evaluate the level of implementation of best practices regarding the use of specific high-alert medications in their hospitals. ISMP will encourage participating hospitals to submit their findings anonymously. Following the completion of data collection and analysis, ISMP will identify and prioritize national opportunities to improve medication safety. They will select one or two key opportunities to build one or more high-alert medication error prevention tools that can be widely used in U.S. hospitals.

Project Goals

  • Create and distribute an instrument to assess safety systems and practices associated with high-alert medications
  • Assess the current state of safety systems and practices associated with high‐alert medications in U.S. hospitals to collect a baseline measure of national efforts
  • Determine the impact of current challenges hospitals face in keeping patients safe during high‐alert medication use
  • Identify and prioritize key opportunities for reducing patient harm in the nation’s hospitals when prescribing, dispensing, and administering high-alert medications
  • Create and distribute tools for healthcare provider teams to redesign their systems and implement safer practices associated with high-alert medications