January 31, 2016: High-Alert Medications Need Multiple Safeguards - Ontario Critical Incident Learning Bulletin
High-alert medications (e.g., opioids, insulin, and anticoagulants) may not be inherently more likely to be involved in medication errors, but they carry an elevated risk of more serious harm to patients if an error occurs with their use. The potential consequences of these errors necessitate multiple enhanced safeguards designed to prevent errors from occurring along the medication-use process continuum, from prescribing and dispensing through to administration and monitoring. Since a single type of intervention is insufficient to ensure the safe use of high-alert medications, a multimodal approach is needed, including higher-leverage, system-based strategies such as constraints, automation, standardization and simplification along with lower-leverage strategies such as education, checklists and double checks.
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