High Alert Medications: Pediatric Patients Revised February 2021
HIGH ALERT SPECIFIC SAFETY STRATEGIES PATIENT MONITORING MEDICATIONS Alprostadil • Independent Double Check prior to Continuous cardiac monitoring administration, where electronic clinical required systems prompt dual sign off upon the following: Initiation of infusion Change of container Handover Anti-arrhythmics, IV • Independent Double Check prior to Continuous cardiac monitoring • Amiodarone administration, where electronic clinical required • Esmolol systems prompt dual sign off upon the • Lidocaine following: • Procainamide Initiation of infusion Change of container Handover Anticoagulants, all routes: • High alert auxiliary label placed on all storage Refer to VUMC Policy - • Alteplase (tPA) locations Anticoagulation Management Program • Apixaban • High Alert auxiliary label placed on all patient and applicable P&T approved • Argatroban specific doses guidelines. • Bivalirudin • Independent Double Check prior to • Defibrotide administration, where electronic clinical • Enoxaparin systems prompt dual sign off • Fondaparinux • Rivaroxaban • Warfarin
Anticoagulant citrate dextrose • High Alert auxiliary label placed on all storage Monitor the circuit and patient ionized formula A (ACD-A) locations calcium per provider order. Monitor for • High Alert auxiliary label placed on all patient signs and symptoms of hypocalcemia. specific doses • CRRT / regional citrate order panel offers bundled medication orders and labs • Independent Double Check prior to administration for CRRT / regional citrate orders, where electronic clinical systems prompt dual sign off upon the following for infusions: Initiation of infusion Change of container Handover Calcium Chloride IV • High Alert auxiliary label placed on all storage Continuous cardiac monitoring locations required during administration • High Alert auxiliary label placed on all patient specific doses. Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Approved by the Pharmacy, Therapeutics and Diagnostics Committee Policy Reference: High Alert Medications
High Alert Medications: Pediatric Patients Revised February 2021
HIGH ALERT SPECIFIC SAFETY STRATEGIES PATIENT MONITORING MEDICATIONS Calcium Gluconate IV • High Alert auxiliary label placed on all storage Continuous cardiac monitoring (excluding calcium containing locations required during administration fluids) • High Alert auxiliary label placed on all patient specific doses • Standardized concentrations available • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Chemotherapy / Biotherapy • Managed by dedicated Oncology Pharmacy Follow monitoring specified in staff treatment plan or therapy plan in • After Hours Dispensing SOP to assure safe electronic clinical system dispensing when dedicated staff are not physically present • Drug files and order sets for electronic clinical systems are developed and maintained by Clinical Oncology Pharmacists • Limited agents are available in pharmacies other than Oncology Pharmacy • Oncology Pharmacists participate in medical center-wide policy/procedure development related to chemotherapy • Auxiliary labels placed on all patient specific doses • Independent Double Check required for order processing and preparation in the pharmacy • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off.
Approved by the Pharmacy, Therapeutics and Diagnostics Committee Policy Reference: High Alert Medications
High Alert Medications: Pediatric Patients Revised February 2021
HIGH ALERT SPECIFIC SAFETY STRATEGIES PATIENT MONITORING MEDICATIONS Controlled Substance PCA and • Automated dispensing cabinets require blind If patient has not received an Continuous Infusion: count upon restock and dispense intermittent dose prior to starting • Continuous Infusion • Limited concentrations available infusion and is not on continuous • Epidural Infusion • Administered utilizing portless tubing monitoring, visually observe patient for • Intraosseous Infusion • Epidural bags and cassettes are prepared by the at least 5 minutes • Intrathecal Infusion pharmacy and labeled with yellow epidural • Patient-Controlled auxiliary labels and are administered utilizing Monitor vital signs, pain, sedation, and Analgesia (PCA) yellow portless tubing respiration at baseline, then every 30 • Subcutaneous infusion • Independent Double Check prior to minutes x 2, then every 4 hours after administration, where electronic clinical the following, and as needed: systems prompt dual sign-off for syringes and upon the following for infusions: . Therapy initiation; . Changes in medication, dose, o Initiation of infusion Change of container concentration or rate of o administration; and o Handover . Adverse event or patient deterioration (e.g. change in sedation score).
For epidurals, also monitor motor function at the same intervals listed above
Refer to: MM SOP – Patient-Controlled Analgesia (PCA) and Continuous Controlled Substance Infusion: Administration and Management
MM SOP – Epidural Administration and Management
Clinical SOP – Intraosseous Infusion
Controlled Substance • Automated dispensing cabinets require blind First doses - If not on continuous Injectable and Intranasal count upon restock and dispense monitoring (e.g., continuous pulse Intermittent Doses: • Limited concentrations available oximetry, telemetry), visually observe • Intranasal patient for at least 5 minutes and again • Intramuscular within one hour • Intraosseous • Intravenous Subsequent Doses – Visually observe • Subcutaneous during administration if not on continuous monitoring NOTE: Testosterone is excluded When administering for minimal sedation, see MM SOP – Minimal Sedation for Procedures and Diagnostic Imaging for monitoring requirements
Approved by the Pharmacy, Therapeutics and Diagnostics Committee Policy Reference: High Alert Medications
High Alert Medications: Pediatric Patients Revised February 2021
HIGH ALERT SPECIFIC SAFETY STRATEGIES PATIENT MONITORING MEDICATIONS Digoxin IV • High Alert auxiliary label placed on all storage Check rate and rhythm of apical pulse locations for (1) one minute prior to • High Alert auxiliary label placed on all patient administration. Hold and notify specific doses provider if: • Ordering restricted to Pediatric Cardiology • Creatinine clearance information available in Patient Age Apical pulse order entry system < 1 year < 100 bpm • Pharmacy kinetic consultation available 1-5 years < 80 bpm
• Limited concentrations available >5 years < 60 bpm • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Epoprostenol (Flolan) • High Alert auxiliary label placed on all storage Continuous cardiac monitoring Inhaled and IV locations required • High Alert auxiliary label placed on all patient specific doses • Back-up patient-specific doses are required Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Heparin Subcutaneous, IV • High Alert auxiliary label placed on all storage Refer to VUMC Policy - bolus and infusion locations Anticoagulation Management Program (excluding heparin flushes, and • High Alert auxiliary label placed on all patient and applicable P&T approved heparin containing IV fluids specific doses guidelines. for line patency) • Premixed solutions are utilized when possible • Standard concentrations available • 40 unit/mL is dispensed in patient specific syringes • Heparin advisor offers dosing recommendations and appropriate monitoring orders • Limited concentrations available • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off for bolus doses and upon the following for infusions: Initiation of infusion Rate Changes Change of container Handover
Approved by the Pharmacy, Therapeutics and Diagnostics Committee Policy Reference: High Alert Medications
High Alert Medications: Pediatric Patients Revised February 2021
HIGH ALERT SPECIFIC SAFETY STRATEGIES PATIENT MONITORING MEDICATIONS Insulin IV bolus and infusion • High Alert auxiliary label placed on all storage Follow monitoring specified in order locations and storage is segregated sets or order panels in electronic • High Alert auxiliary label placed on all patient clinical systems specific doses • Standardized concentrations available • Insulin advisor offers dosing recommendations and appropriate monitoring orders • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off for bolus doses and upon the following for infusions: Initiation of infusion Change of container Handover
Insulin Subcutaneous: • High Alert auxiliary label placed on all storage Follow monitoring specified in order locations and storage is segregated sets or order panels in electronic • High Alert auxiliary label placed on all patient clinical systems specific doses • Insulin glargine (Lantus®) provided only inpatient specific syringes • Insulin advisor offers dosing recommendations and appropriate monitoring orders • Diluted insulin is dispensed in patient specific vials for inpatient use • Diluted insulin is dispensed in patient specific syringes for clinic use • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Magnesium Sulfate IV • High Alert auxiliary label placed on all storage Continuous cardiac monitoring during (excluding magnesium locations administration for rates exceeding 50 containing fluids) • High Alert auxiliary label placed on all patient mg/kg/hr specific doses • Limited concentration of premix solution (2000mg/50mL) • Not dispensed in concentrated form • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Approved by the Pharmacy, Therapeutics and Diagnostics Committee Policy Reference: High Alert Medications
High Alert Medications: Pediatric Patients Revised February 2021
HIGH ALERT SPECIFIC SAFETY STRATEGIES PATIENT MONITORING MEDICATIONS PARALYZING AGENTS: • Warning: Paralyzing Agent auxiliary label Continuous cardiac monitoring and • Cisatracurium placed on all storage locations and patient pulse oximetry for the duration of • Rocuronium specific doses in all locations treatment and/or as directed by • Succinylcholine • High Alert auxiliary label placed on all patient provider order • Vecuronium specific doses • Storage is segregated • Limited product availability in pharmacy and automated dispensing systems (e.g., critical care areas only) • Standardized nomenclature utilized in eStar and AcuDose: “PARALYZING AGENT” followed by the medication name • Pop-up warning in AcuDose and Alaris pump: WARNING: PARALYZING AGENT - Causes Respiratory Arrest – Patient Must Be Ventilated • Shrink wrap packaging added to vials • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off for bolus doses and upon the following for infusions: Initiation of infusion Change of container Handover
Potassium and Sodium Acetate • High Alert auxiliary label placed on all storage Continuous cardiac monitoring during IV (excluding potassium and locations administration sodium containing fluids) • High Alert auxiliary label placed on all patient Monitoring requirements included in specific doses ordering panel • Not dispensed in concentrated form Refer to MM SOP - Intravenous • Storage is segregated in the pharmacy Potassium for Pediatric Patients • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Potassium Chloride IV • High Alert auxiliary label placed on all storage Continuous cardiac monitoring during (excluding potassium locations administration containing fluids) • High Alert auxiliary label placed on all patient Monitoring requirements included in specific doses ordering panel • Potassium Chloride 2 mEq/mL vials are only Refer to MM SOP - Intravenous issued in the OR for sclerosing veins Potassium for Pediatric Patients • Storage is segregated in the pharmacy • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Approved by the Pharmacy, Therapeutics and Diagnostics Committee Policy Reference: High Alert Medications
High Alert Medications: Pediatric Patients Revised February 2021
HIGH ALERT SPECIFIC SAFETY STRATEGIES PATIENT MONITORING MEDICATIONS Potassium and Sodium • High Alert auxiliary label placed on all storage Continuous cardiac monitoring during Phosphate IV locations administration (excluding potassium and • High Alert auxiliary label placed on all patient Monitoring requirements included in sodium containing fluids) specific doses ordering panel • Not dispensed in concentrated form Refer to MM SOP - Intravenous • Storage is segregated in the pharmacy Potassium for Pediatric Patients • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Sodium Chloride • High Alert auxiliary label placed on all Perform neuro checks and serum labs (Concentrations greater than storage locations per provider orders 0.9%) IV • High Alert auxiliary label placed on all patient specific doses • Limited concentrations of premixed solutions (3% only) • Storage is segregated • Sodium Chloride 3% bags are placed in a High Alert bag for dispensing in Automated Dispensing System • Sodium Chloride 23.4% injection is dispensed in oral syringes in concentrated form only for oral sodium supplementation • Independent Double Check prior to IV administration, where electronic clinical systems prompt dual sign off
Treprostinil (Remodulin) • High Alert auxiliary label placed on all storage Continuous cardiac monitoring IV and subcutaneous locations required • High Alert auxiliary label placed on all patient specific doses • Independent Double Check prior to administration, where electronic clinical systems prompt dual sign off
Vasoactive and Inotropic • Independent Double Check prior to Continuous cardiac monitoring Continuous Infusion administration, where electronic clinical required • DOBUTamine systems prompt dual sign off upon the • DOPamine following: • EPINEPHrine Initiation of infusion • Milrinone Change of container • NiCARdipine Handover • Nitroprusside • Norepinephrine • Phenylephrine • Vasopressin
Approved by the Pharmacy, Therapeutics and Diagnostics Committee Policy Reference: High Alert Medications