ProMedica
Clinical CareInterdisciplinary / NursingPolicy and ProcedurePolicy # 1012Page 1 of 5This document is an official document of ProMedica. If it needs changed in any way, please contact Clinical Practice Improvement.? ProMedica Toledo Hospital? ProMedica Bay Park Hospital? ProMedica Wildwood Orthopedic & Spine Hospital? ProMedica Defiance Regional Hospital? ProMedica Toledo Children’s Hospital? ProMedica Fostoria Community Hospital? ProMedica Flower Hospital? ProMedica Bixby Hospital? ProMedica St. Luke’s Hospital? ProMedica Herrick Hospital? Lima Memorial? ProMedica Memorial Hospital? ProMedica Monroe Regional HospitalAge Specific Populations ? Adult ? Pediatric (any patient not in the Newborn Nursery or Neonatal Intensive Care Unit, less than or equal to 17 years)? Neonate (in the Newborn Nursery or Neonatal Intensive Care Unit)Section: 10 MedicationsPolicy #: 1012 (EPIC) High Risk Medications Requiring an Independent Double Check Initial Effective Date: 4/5/2016Reviewed Date:Revised Date: TITLE: (EPIC) High Risk Medications Requiring an Independent Double Check PURPOSE: To assure safe and accurate administration of medications designated as High Alert Medications. POLICY: High Alert Medications are double checked independently by two licensed practitioners with authority to administer the medication. In the event that two practitioners with authority to administer are not available, a pharmacist or other practitioner with appropriate knowledge base may serve as the second practitioner. The independent double check includes verification that the correct patient receives the correct medication, in the correct dose, by the correct route, at the correct time, with appropriate documentation (6 Rights of Medication Administration). The independent double check includes comparison of the medication to the order and the electronic or paper medication administration record. It is documented in the electronic or paper medication administration record in accordance with business unit policies. Independent double checks occur with each administered dose. For infusions, double checks occur at the time of:Initiation of therapyConcentration/bag/syringe changeBolus doseDose/rate changeHandoff of care, including shift changeA list of High Risk Medications Requiring an Independent Double Check is provided in Attachment A. BUSINESS UNIT- SPECIFIC POLICY: **At PTH, all narcotic infusions are double checked independently in accordance with the policy and procedure statements included herein. PROCEDURE:The licensed practitioner with authority to administer reviews the current medication orders and identifies medications requiring double check.At the bedside, the licensed practitioner with authority to administer checks the items listed below and another licensed practitioner with authority to administer independently checks the same items. In the event that two practitioners with authority to administer are not available, a pharmacist or other practitioner with appropriate knowledge base may serve as the second practitioner. When a student participates in the administration of a high risk medication, the double check is performed by the student and another licensed practitioner with authority to administer. The student may then administer the medication under the direct supervision of the instructor/preceptor. NOTE: In the NICU, IV therapy is only observed by the student. For pediatric patients, students may not administer TPN or lipids, or medications administered for the purpose of moderate sedation. For pediatric patients, only students in a senior level practicum may administer IV push medications to appropriate patients at the discretion and under the direct supervision of the preceptor.The independent double check includes:Patient name as it appears on the medication administration record (MAR/e-MAR)Medication to be administeredDose of medication, including any calculations and pump settingsThe medication packaging or vial is verified when the medication is prepared (i.e. insulin doses)Route of administrationIf IV, this includes appropriate pump/channel, rate, and infusion siteTime/frequency of administrationPertinent vital signs and/or laboratory valuesPatient identity matching two identifiers associated with the medication order to the same two identifiers on the patient’s armband or patient/patient’s representative verbal statementHigh Alert Medications administered by infusion are delivered through a separate dedicated channel using the smart pump guardrails features.Insulin independent double check includes verification of the most recent blood glucose by both practitioners.Heparin independent double check includes verification of the most recent PTT by both practitioners.The pharmacy label of the TPN/PPN is compared with the MAR/e-MAR, and the order.Chemotherapeutic agents are administered in accordance with ProMedica Cancer Institute policy 1401 - Cancer Chemotherapy Order Processing. Of note:New orders for chemotherapeutic agents administered for the treatment of cancer are double checked (including dosing calculations) by two chemotherapy trained licensed practitioners. In the event that two chemotherapy trained licensed practitioners are not available, a pharmacist or other practitioner with appropriate knowledge base may serve as the second practitioner. Each dose is double checked, at the bedside in accordance with ProMedica Cancer Institute policy 1401 - Cancer Chemotherapy Order Processing. Chemotherapeutic agents administered for reasons other than the treatment of cancer are double checked at the bedside by two licensed practitioners with authority to administer.The documentation of the independent double check is completed by use of Dual RN Sign in the eMAR or by both practitioners signing the paper MAR or other specified chart document (i.e. PCA flow sheet). When a student is involved in the administration of a high risk medication, the documentation of the double check is performed by the student and another licensed practitioner with authority to administer. The administering licensed practitioner with authority to administer observes the patient for desired outcomes and adverse reactions.REFERENCES:Lippincott (2015). General Medication Practices. Accessed at , C. (2009). Medication Safety and Quality Part 3: Managing High-Alert Medications.Pharmacy Practice News, April 2009, 10-11.The Joint Commission. Republication Requirements. December 18, 2013.ISMP List of High Alert Medications in Acute Care Settings. 2014. Accessed at Anderson, A., Townsend, T. (2015). Preventing High Alert Medication Errors in Hospital Patients.American Nurse Today 10(5), 18-23.Pfoh, E., Thompson, D., Dy, S. Part 2a. Practices Designed for a Specific Patient Safety Target Section A. Adverse Drug Events Chapter 3. High Alert Drugs: Patient Safety Practices for Intravenous Anticoagulants. Making Healthcare Safer II: An Updated Critical Analysis of the Evidence forPatient Safety Practices. (2014), 23-29.Cohen, MR, Smetzer, JL., Tuohy, NR., et al. High-alert Medications: Safeguarding against errors. In:Medication Errors. Cohen, MR ed.; Washington, DC: The American Pharmacist Association.(2007), 317-412.ORIGINATED BY: ENDORSED BY: ProMedica Nursing Practice and Informatics Council- 10/09/2015ProMedica Drug Policy Development Committee – 1/4/2016APPROVED BY: ProMedica Acute Care Nurse Executives Council- ProMedica Pharmacy and Therapeutics Committee-1/28/2016ProMedica Bay Park Hospital Medical Executive Council- 2/2/2016ProMedica Bixby and Herrick Hospitals Medical Executive Council- 2/10/2016ProMedica Defiance Hospital Medical Executive Council- 2/1/2016ProMedica Flower Medical Executive Council- 2/15/2016ProMedica Fostoria Medical Executive Council- 2/16/2015ProMedica Memorial Medical Executive Council- 2/15/2016ProMedica St. Luke’s Hospital Medical Executive Council- 2/2/2016 ProMedica Toledo Hospital Medical Executive Council- 2/9/2016AdultPediatricNeonateInsulin (any route)Insulin (any route)Insulin (any route)PCA infusions & Epidural InfusionsAll IV Controlled Substances including Drips/PCA’s & EpiduralsAll IV Controlled Substances (regardless of route)IV Heparin (with the exception of pre-filled flush syringes)All Anticoagulants (with the exception of pre-filled flush syringes and heparinized solutions)All Anticoagulants (with the exception of pre-filled flush syringes and heparinized solutions)Argatroban------------------Chemotherapeutic agents (any route for any purpose)Chemotherapeutic agents (any route for any purpose)Chemotherapeutic agents (any route for any purpose)Magnesium infusions in obstetricsAll IV concentrated electrolytesAll IV concentrated electrolytesThrombolytic enzymes (with the exception of Cathflo for de-clotting central or mid-line catheters)Thrombolytic enzymes (with the exception of Cathflo for de-clotting central or mid-line catheters)--------TPN and PPN (Total parenteral nutrition and peripheral parenteral nutrition)TPN and PPN (Total parenteral nutrition and peripheral parenteral nutrition)TPN and PPN (Total parenteral nutrition and peripheral parenteral nutrition)KCentra, FEIBA, & Factor ConcentratesBlood derived products & Factor ConcentratesBlood derived products (albumin, novoseven, IVIG)ParalyticsParalyticsIV SedativesIV Cardiac MedicationDigoxinIV DiureticsAnti-arrhythmicsIV MethylxanthinesVasoactive InfusionsAminoglycosides/VancomycinNifedipineAttachment A: Designated High Risk Medications Requiring an Independent Double Check ................
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