Management of High-Alert Medications – Hospital Pharmacy..

 

Standard Operating Procedure (SOP)
Management of High-Alert Medications – Hospital Pharmacy

 

1. Purpose

To minimize the risk of serious medication errors associated with high-alert medications by ensuring safe prescribing, storage, dispensing, administration, and monitoring within the hospital.

2. Scope

This SOP applies to all high-alert medications used in the hospital, including pharmacy, OPD, IPD, ICU, OT, Emergency, and wards.

3. Responsibility

• Hospital Management: Support and enforcement of medication safety policies
• Pharmacy Manager / Chief Pharmacist: Identification, implementation, and monitoring of high-alert medication practices
• Pharmacists: Safe dispensing, labeling, and counseling
• Medical Officers: Safe prescribing and review
• Nursing Staff: Safe administration and monitoring
• Quality / Patient Safety Team: Audit and incident review

4. Definitions

• High-Alert Medications: Drugs that have a high risk of causing significant patient harm when used in error
• Independent Double Check: Verification by two qualified healthcare professionals independently

5. Examples of High-Alert Medications

(Common examples; hospital-specific list should be maintained)

• Insulin (all types)
• Heparin and Low Molecular Weight Heparin
• Potassium chloride (concentrated)
• Magnesium sulfate
• Chemotherapy agents
• Narcotic analgesics (e.g., morphine, fentanyl)
• Thrombolytics
• Neuromuscular blocking agents

Read About: What is hyperkalemia

6. Procedure

6.1 Identification and Listing

• A High-Alert Medication List shall be:
• Prepared by the Pharmacy Department
• Approved by the Drugs & Therapeutics Committee (DTC)
• Reviewed annually or as required
• High-alert medications shall be clearly identified with warning labels

6.2 Prescribing

• Prescriptions for high-alert medications must be:
• Clear and legible
• Include patient weight (where applicable)
• Specify dose, route, frequency, and duration
• Verbal orders shall be discouraged and minimized
• Dose calculations must be double-checked

6.3 Storage

• High-alert medications shall be:
• Stored separately from routine medications
• Clearly labeled “HIGH-ALERT MEDICATION.”
• Concentrated electrolytes shall:
• Not be stored in patient care areas (where possible)
• Access shall be restricted

6.4 Dispensing

• Dispensing shall be done only by authorized pharmacists
• An independent double check shall be performed before dispensing
• Dispensed medications shall be:
• Clearly labeled
• Accompanied by special handling instructions
• Look-Alike / Sound-Alike (LASA) precautions shall be followed

6.5 Administration

• Nursing staff shall:
• Verify patient identity using two identifiers
• Perform an independent double check before administration
• Follow the “Five Rights” of medication administration
• Infusion pumps shall be used where required
• Administration shall be documented immediately

6.6 Monitoring

• Patients receiving high-alert medications shall be:
• Closely monitored for adverse effects
• Monitored as per clinical guidelines
• Any abnormal findings shall be reported immediately

6.7 Error Reporting

• Medication errors or near misses involving high-alert medications shall be:
• Reported immediately
• Documented in the medication error reporting system
• Root cause analysis shall be conducted

6.8 Education and Training

• All healthcare staff shall receive:
• Initial training on high-alert medications
• Periodic refresher training
• Training records shall be maintained

7. Documentation

• High-Alert Medication List
• Prescriptions and medication charts
• Dispensing and administration records
• Double-check documentation
• Medication error reports

8. Audit and Quality Improvement

• Regular audits shall be conducted to ensure compliance
• Audit findings shall be reviewed and corrective actions implemented

9. Review

This SOP shall be reviewed:

• Annually, or
• When new high-alert medications are introduced

10. References

• NABH Patient Safety Standards
• WHO Patient Safety Guidelines
• Institute for Safe Medication Practices (ISMP)
• Hospital Pharmacy Policy

11. Approval

• Prepared by: __________________
• Reviewed by: __________________
• Approved by: __________________
• Effective Date: ________________
• Review Date: __________________