High Risk Medications can be defined as those which have a heightened risk of causing catastrophic harm if a medication incident occurs. Although medication incidents may or may not be more common with these medications, the consequences of an error can be more devastating to patients and may increase health care costs. Often they are medications with a low therapeutic index or medications that presents a high risk when administered via the wrong route.

To define a list of High Risk Medications used at Grampians Health Ballarat, and to provide a risk assessment tool utilising risk reduction strategies to ensure that High Risk Medications are stored, distributed, prescribed, dispensed, administered, monitored and disposed of as safely as possible.

ACSQHC: Australian Commission on Safety and Quality in Healthcare.

ISMP: Institute for Safe Medication Practices (Pennsylvania, USA).

Low therapeutic index: where the toxic dose and therapeutic dose of a medicine are very similar.

Medication: refers collectively to medications, medicines, drugs or therapeutic agents administered by any route.

Medication Management Pathway: see Appendix 1.

Medication Safety: describes the systems and strategies necessary to ensure clinicians safely store, distribute, prescribe, manufacture, dispense and administer appropriate medication to informed patients and/or carers.

MSGC: Medication Safety Governance Committee

Patient: in this policy will refer to patients, clients or residents.

Riskman: electronic incident reporting management system. This term is also includes VHIMS Riskman.

Grampians Health Ballarat defines the following medications/classes as High Risk (see Appendix 2 for list):

Those identified by the APINCH acronym as developed by the ACSQHC

A          Anti-infectives

P          Potassium and other electrolytes

I           Insulin

N         Narcotics and other sedatives

C         Chemotherapeutic agents

H         Heparin and other anticoagulants

Others as identified by the MSTC

Neuromuscular blockers

Clozapine

Systems (e.g. infusion pumps and oral dispenser enteral feeding systems with unique connections)

Grampians Health Ballarat High Risk Medications Risk Reduction Strategies and Assessment

• The risks associated with medication use are rarely controlled by one safety strategy, but rather by a combination of strategies that assist to build a safety net to eliminate error or mitigate risk. These range from 'high-leverage' (not dependent on human vigilance to be successful) through to 'low-leverage' (dependent on individuals doing the right thing) - see Table 1: Error Reduction Strategy Hierarchy. Multiple strategies are preferred to increase the chance of the safety net preventing errors, with as many options from the top of the table as possible.

• High Risk Medications require a risk reduction assessment (utilising risk reduction strategies) to be undertaken and implemented for each medication/class defined as High Risk (see Appendix 2), including all appropriate stages of the medication management pathway. These reviews are conducted using the framework provided by the ISMP Key Safety Principles (see Appendix 3) and recorded on the BHS High Risk Medications Risk Reduction Assessment Tool (see Appendix 4).

• Other risk assessments using validated tools identified by organisations such as the ACSQHC will be undertaken for individual High Risk Medications where they are appropriate.

• Electronic systems will be utilised where available and practical, to support the safer procuring, storing and distributing, prescribing, dispensing, administering, disposal and monitoring for response to medication (e.g. ARIA, CAM ).

For all High Risk Medications, all  staff involved in the Medication Management Pathway must:

Document incidents involving High Risk Medications in Riskman as per Incident Management NCP0041.

• Include details of any High Risk Medications that the patient is prescribed in clinical handover. See Medication Management POL0077 for more information.

• Where practical, request that the Clinical Pharmacist or Pharmacy Department review and annotate the order of High Risk Medications before they are administered, especially when clinical staff are unfamiliar with the medication. The Clinical Pharmacist will also provide any information required to the patient and to staff administering medication.

The MSGC will:

• Be responsible for monitoring incidents and alerts related to High Risk Medications, and overseeing the implementation of risk reduction strategies.

• Coordinate the review of High Risk Medications using the BHS High Risk Medications Risk Reduction Assessment Tool (see Appendix 4) or other validated tools every three years or earlier if required.

• Implement and review quality improvement activities relating to High Risk Medications.

• Identify and facilitate creation of a Drug Guideline for a High Risk Medications where one does not already exist and is required

• Ensure policies, procedures and guidelines for High Risk Medications (where required) are available on the Governance Documentation system.

• Ensure a list of High Risk Medications (see Appendix 2) is available to all clinical areas. High Risk Medications will be highlighted by the use of a distinguishing barcode, poster or other shelf sign in medication storage areas in the pharmacy and clinical areas.

• Be responsible for reviewing new medications and assessing if they are High Risk. Completing a risk assessment for High Risk Medications

• Monitor (and act where applicable) to alerts and recommendations regarding High Risk Medications from institutions such as:

- ACSQHC

- The Council of Australian Therapeutics Advisory Group

- Victorian Therapeutics Advisory Group

- Department of Health - Victoria

- Clinical Excellence Commission NSW Health

- ISMP

- Any other relevant source.

• Disseminate relevant Medication Safety information, alerts and recommendations regarding High Risk Medications to all staff involved in the Medication Management Pathway via the Medication Safety website, Medication Safety newsletter, posters, email and education sessions as required.

Evaluation

Regular review of systems: the Medication Safety Self Assessment, Medication Safety Self Assessment for Antithrombotic Therapy and International Medication Safety Self Assessment for Oncology are all conducted three yearly.