High-Risk Medication Management Policy

Transcription

1 Department of Health and Human Services SYSTEM PURCHASING AND PERFORMANCE - MEDICATION STRATEGY AND REFORM High-Risk Medication Management Policy SDMS Id Number: Effective From: May 2014 Replaces Doc. No: Custodian and Review Responsibility: Contact: Applies to: Policy Type: Policy ID (as assigned by Corporate Document and Information Services) New Review Date: May 2017 Keywords: Routine Disclosure: SPP Medication Strategy and Reform Director Medication Strategy and Reform THO-North, THO-South, THO-North West DHHS Statewide Policy High-risk, medication, safety, risk Yes Approval Prepared by Sulfi Newbold Medicines Policy Officer May 2014 Through Through Cleared by Anita Thomas Senior Specialist Pharmacist Quality Use of Medicine THO-N Medication Management and Safety Committee THO-NW Medication Safety & Improvement Committee THO-S Quality Use of Medicine Committee John Kirwan Karen Linegar Matthew Daly THO-N Chief Executive Officer THO-NW Acting Chief Executive Officer THO-S Acting Chief Executive Officer May May June June June 2014 Revision History Version Approved by name Approved by title Amendment notes This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Department of Health and Human Services Strategic Document Management System. Any printed version is uncontrolled and therefore not current. Page 1 of 5

2 Purpose This policy aims to define which medications are considered to be high-risk, and to address and reduce the risks associated with the prescribing, dispensing and administering of these high-risk medications. Errors associated with high-risk medications are more likely to result in devastating outcomes. All Tasmanian Health Organisation (THO) Services must recognise and address the need for more stringent protocols and practices surrounding these medications. Mandatory Requirements Each THO service must establish the following to mitigate the risks associated with high-risk medications: Each high-risk medication (or high-risk medication group) must be the subject of a local protocol/procedural document outlining the appropriate and safe mechanisms by which staff should manage this medication. Each protocol must also outline the appropriate method of patient monitoring for the relevant therapy. Each THO service must have a risk management process available, suitable for identifying and reporting medication risks, including high-risk medications. Medication Safety and Improvement Committees (MSIC) must review any risks identified in the risk management process, and develop and implement a strategy to address these risks. Medication incidents involving high-risk medications must be reported in the approved hospital incident reporting system. At a minimum, services must adopt their definition of high-risk medications to be consistent with those described in the A PINCHS table (see Appendix 1). Any site may choose to add further medications to their high-risk medication list. This policy should be used to direct the development of detailed individual procedures and guidelines around medication handling for THO services that store and/or administer medications that are identified as high-risk, in order to meet regulatory requirements and satisfy NSQHS Standard 4 in medication safety. Any medication errors, mishaps or near-misses associated with high-risk medications must be reported in the approved incident management system, as per DHHS policy. Any identified risks involving high-risk medications must be reported to the area manager by the identifying staff member, and escalated by the manager, where appropriate, through the organisation s risk management process. Identified risks must be acted upon according to local protocol. This is a statewide policy and must not be re-interpreted so that subordinate policies exist. Should discreet operational differences exist, these should be expressed in the form of an operating procedure or protocol. Failure to comply with this policy, without providing a good reason for doing so, may lead to disciplinary action. This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Department of Health and Human Services Strategic Document Management System. Any printed version is uncontrolled and therefore not current. Page 2 of 5

3 Roles and Responsibilities/Delegations Health organisation staff have an individual responsibility for adhering to local protocols regarding medication management and handling. Service managers are responsible for ensuring that staff are able to appropriately and safely undertake their role in relation to medication management. Executive managers are responsible for facilitating implementation and oversight of the policy through governance arrangements and ensuring the provision of adequate and sustainable resources. Risk Implications Errors or misadventure associated with high-risk medications are more likely to be associated with devastating patient outcomes. Training All clinical staff must read relevant policies and procedures relating to their scope of practice prior to dealing with high risk medications and complete any associated training regarding the management of high-risk medications within their scope of practice. Audit This policy will be included in the work program of the DHHS Internal Audit function. This work program is approved by the Audit and Risk Committee and will assess underlying systems and procedures for compliance with the requirements of this policy. The overall focus of this assessment will be one of continuous improvement to DHHS activities. Attachments 1 Appendix 1 - High Risk Medicines Page 3 of 5

4 Appendix 1 High Risk Medicines Definition: Medicines that have a high risk of causing serious injury or death to a patient if they are misused. Errors with these products are not necessarily more common, but the effects can be more devastating. The following medications are recognised internationally as High-Risk Medicine groups. 1 Medication Safety and Improvement Committees should maintain a register of high risk medications, develop initiatives to raise awareness of known risks associated with these medications and provide tools/protocols to facilitate risk minimisation. The minimum medicine groups for inclusion in the register are listed below. A PINCHS High risk medicines The following table is not intended to be an exhaustive list but rather a guide to high risk medications. High Risk Medication Group Examples of medication A: Anti-infectives Amphotericin Aminoglycosides Vancomycin P: Potassium and other electrolytes Injectable potassium (and other concentrated electrolyte injections) I: Insulin All insulins N: Narcotics and other sedatives Hydromorphone, oxycodone, morphine, fentanyl, alfentanil, remifentanil, etc. Benzodiazepines Thiopentone, propofol and other short acting anaesthetics C: Chemotherapeutic agents Vincristine Methotrexate Buprenorphine and methadone H: Heparin and other anticoagulants Heparin Warfarin New oral anticoagulant agents S: Systems Oral dispensers Independent double checks for patient controlled analgesia High alert drugs and infusion pumps Page 4 of 5

5 Other Mental health medicines including (but not limited to) lithium and clozapine High risk medications identified at local site level which do not fit into the above categories. 1. ISMP s List of High-Alert Medications. Institute for Safe Medication Practices, (Accessed 17 January 2013, at Page 5 of 5