Improving medication management entails not only reducing errors, but also implementing changes that reduce harm or adverse events. Not all harm is the result of errors. Some harm may be prevented by improving medication management, changing prescribing patterns, adding other therapies to minimize untoward side effects, and identifying harm in time to mitigate it before it becomes serious.
The Joint Commission, referring to ISMP’s work, describes high-alert medications as those medications that bear a heightened risk of causing significant harm to individuals when they are used in error. Based on reports submitted to ISMP, a review of the literature, and the experience of many hospitals around the country, the list of high-alert medications includes as many as 19 categories and 14 specific medications. Although it is important to improve management of all of these medications some of them have been associated with harm more frequently than others.
Based on findings from the use of the IHI Global Trigger Tool and the experience of hospitals that have participated in the Institute for Healthcare Improvement’s (IHI's) Collaboratives, this How-to Guide focuses on four groups of high alert-medications -- anticoagulants; narcotics and opiates; insulins; and sedatives -- because they represent areas of greatest harm and greatest opportunity for improvement. The most common types of harm associated with these medications include hypotension, bleeding, hypoglycemia, delirium, lethargy, and oversedation. IHI recommends that teams begin improving processes with at least one of these medication groups and then expand to include all four groups.