Policies,Clinical,UWHC Clinical,UWHC-wide,Patient Care

High Alert Medication Administration (8.33)

High Alert Medication Administration (8.33) - Policies, Clinical, UWHC Clinical, UWHC-wide, Patient Care


As of February 1, 2017, this policy applies to the operations and staff of legacy UWHC. Effective July 1,
2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of
Wisconsin Hospitals and Clinics Authority (UWHCA). All policies are being transitioned to apply
UWHCA-wide, but until future revision to this policy #8.33, it applies only to the operations and staff of
legacy UWHC.

8.33 High Alert Medication Administration
Category: UWHC Policy
Policy Number: 8.33
Effective Date: February 1, 2017
Version: Revision
Section: Patient Care

A. To identify High Alert Medications requiring special prescribing, storage, handling, dispensing and
administration procedures to maximize patient safety, and to describe these procedures.
B. To increase awareness of High Alert Medications and their potential risks and special handling procedures
among providers, thereby improving patient safety.

High Alert Medication: Medications as listed in this policy that pose a heightened risk of causing significant
patient harm or injury when they are administered in error. Although mistakes may or may not be more common
with these medications, the consequences of an error associated with their use are more devastating to
patients. The following considerations are used to determine the classification of a medication as high alert:
A. How medication is dispensed: The dose administered by the nurse requires manipulation of the
dose. When there are doses of medications provided from pharmacy that are not the same as the dose to
be given or require manipulation or calculation by the nurse to arrive at the desired dose, there is a higher
likelihood that the medication should require a double-check.
B. Ability to rapidly assess the impact of the medication on the patient: If there is not a quick way to
facilitate identification of an error (e.g., such as continuous vital sign monitoring for a patient on
vasopressor drips), then high-alert status may be warranted (e.g., heparin).
C. Medication administered via an epidural or intrathecal route are high-alert.
D. Investigational Drugs and/or drugs provided under a clinical research protocol are high alert.
E. Prevention measures in place for this product: Items that have safety features in place (e.g., pumps with
infusion decision support/alerts) in general do not need a double-check.
Independent double-check: An independent second verification by another licensed professional of the
medication label, dose (including calculations), route, frequency, patient, equipment, lines and/or programmed rate
of infusion versus the original order or pharmacy-approved medication administration record.

A. UW Health will maintain safe practices for storing, prescribing, handling, dispensing and administering
High Alert Medications across all sites of care, including inpatient, ambulatory, perioperative, procedure
areas and the emergency department.
B. Chemotherapy agent double-check procedures are described elsewhere (refer to Hospital Policy #8.59,
"Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation, and
Patient/Family Education" and other related policies).
C. High Alert Medications include the following medications:
1. Adrenergic agents parenteral/injectable (e.g., epinephrine, phenylephrine, norepinephrine).
2. Antithrombotic agents (anticoagulants) including IV heparin (< 500 unit flushes are exempt),
Factor Xa inhibitors (e.g., fondaparinux), direct thrombin inhibitors (e.g., argatroban, lepirudin,
bivalirudin), thrombolytics (e.g., alteplase, reteplase, tenecteplase) and glycoprotein IIb/IIIa
inhibitors (e.g., eptifibatide); excluding alteplase low dose injections for line clearance and
anticoagulant citrate compound.
3. IV Anesthetics (for example, ketamine, propofol, etomidate, methohexital, and thiopental).
4. Epidural infusions of any medication (refer to Hospital Administrative policy 8.92-Epidural and
Intrathecal Analgesia).

5. Intrathecal medications (refer to Hospital Administrative policy 8.92-Epidural and Intrathecal
Analgesia and Nursing Departmental Patient Care policy 10.14-Access to Intrathecal Reservoirs
and administration of Medications including Chemotherapeutic Agents).
6. Monoclonal antibodies (e.g., basiliximab, infliximab, omalizumab, rituximab) when they are used
for non-oncologic indications.
7. Neuromuscular blocking agents (e.g., atracurium, cisatracurium, pancuronium, rocuronium,
succinylcholine, vecuronium, etc.).
8. Opioid continuous infusions.
9. Patient Controlled Analgesia (PCA) infusions of any medication.
10. Therapeutic radiopharmaceuticals are considered high-alert medications. Note that double-check
procedures for these medications are described elsewhere (refer to the Therapeutic
Radiopharmaceutical Standard Operating Procedure maintained in Nuclear Medicine).
11. Total Parenteral Nutrition (TPN) solutions.
12. CVVH replacement fluid administered to pediatric patients.
13. Amiodarone infusions and for injection.
14. Antithymocyte Globulin (ATG) for injection.
15. Bumetanide infusions.
16. Dexmedetomidine infusions.
17. Diltiazem infusions.
18. Dopamine infusions.
19. Dobutamine infusions.
20. Epoprostenol (Flolan) inhalations and infusions.
21. Esmolol infusions.
22. Fenoldopam infusions.
23. Furosemide infusions.
24. Inamrinone infusions.
25. Insulin, subcutaneous, IV infusions and injections (all insulin products including regular, as part,
NPH, glargine, etc.).
26. Labetalol infusions.
27. Lidocaine infusions (subcutaneous and intravenous).
28. Lorazepam infusions.
29. Midazolam infusions.
30. Milrinone infusions.
31. Naloxone infusions.
32. Nesiritide infusions.
33. Nicardipine infusions.
34. Nitroglycerin infusions.
35. Nitroprusside infusions.
36. Procainamide infusions.
37. Promethazine parenteral/injectable.
38. Sodium chloride hypertonic solutions for infusion(>0.9%).
39. Treprostinil intravenous infusions.
40. Vasopressin infusions.
41. Verapamil infusions.
D. Exceptions to the procedures outlined below include emergency resuscitative events where safety labeling
and handling precautions would delay treatment and negatively impact care delivery.
E. Initial competency for administering High Alert Medications will be assessed during orientation of new
F. UWHC will maximize the use of standardized concentrations for intravenous infusions of medications.

A. ALL SITES OF CARE (Inpatient, clinics, procedural, perioperative and emergency department). Safety
procedures during the ordering, preparation, dispensing and administration of High Alert Medications
1. Prescribing.
a. Verbal orders for High Alert Medications are discouraged (see Hospital
Administrative policy 8.16-Patient Care Orders for detailed verbal order processing
2. Storage, handling, preparation and dispensing - Identification of High Alert Medications.
a. The pharmacy department will maintain segregated, clearly labeled storage locations
(e.g., bins, locked pockets, etc.) for all High Alert Medications stored in patient care

areas, with a distinct high-alert medication warning label visibly placed on the storage
bin, excluding emergency medication stock locations.
b. For High Alert Medications stocked in the AcuDose cabinets and available either through
inventory dispense or override modes, a reminder message will appear on the AcuDose
dispense screen to alert the nurse to the High Alert status of the medication.
c. Each pocket containing a High Alert Medication stocked in AcuDose cabinets will be
prominently labeled to alert the nurse to the High Alert status of the medication as the
medication is retrieved from the AcuDose pocket.
d. High Alert patient-specific infusions which are dispensed from the pharmacy will be
clearly labeled as such with the following wording, which is readily distinguishable from
the rest of the label:
!!!HIGH ALERT - Requires Double-Check!!!
e. The electronic medication administration record (if applicable) for each High Alert
Medication will also include notification that the medication is high alert.
f. The potential for drug name confusion between morphine and hydromorphone is
high. Therefore, a visual alert will be posted on AcuDose pockets containing
hydromorphone to clearly distinguish it from morphine and to prevent possible errors.
3. Administration of Medication.
a. An independent double-check is required at the following times:
i. Directly prior to the administration of a high alert medication including prior to
every high alert medication infusion bag or syringe change.
ii. At shift change for every high alert medication infusion bag or syringe.
iii. Upon patient transfer for every high alert medication infusion bag or syringe.
iv. When the programming of an infusion pump rate setting is outside the IV
infusion pump decision support software (e.g., Alaris Guardrails™) dosing
v. When programming a PCA pump, at initial setup and with any reprogramming
as well as handoffs.
vi. Double-checks for every non-PCA continuous infusion rate change are not
b. Procedures for independent double-checks:
i. Independent double-check must be performed by another licensed professional
(e.g., nurse, physician, pharmacist or other licensed independent practitioner)
who is credentialed and competent to order, prepare, dispense, or administer
the medication.
ii. If the medication is an infusion, the individual completing the independent
double-check should verify that the intended infusion is being delivered through
the intended channel by physically tracing the line from the medication,
through the pump, and to the insertion site.
iii. Those who are completing the independent double-check should conduct the
process with a high level of vigilance, such that he or she would feel
comfortable ordering, dispensing, or administering the medication(s)
themselves and they should not be prompted as to the medication name, dose
and/or rate they are expected to verify.
c. All high-alert continuous intravenous medication infusions must be administered via an
IV pump. Each infusion line must be labeled with the name of the medication being
infused at the distal ends of all tubing so that two providers can independently trace the
line back to the insertion for confirmation.
d. In code or near-code situations when the nurse or physician determines that the
urgency of a patient's clinical condition warrants bypassing the above independent
double-check procedures, the provider administering the medication should announce all
drug therapy to another health-care provider immediately before administration saying,
for example, "I am now giving heparin 2,000 units IV."
e. In care settings where the electronic medication administration record and bar code
medication administration system is used to document medication administration, this
software will assist in reminding caregivers of the required independent double check
and require documentation of this double-check prior to documentation of medication
1. In circumstances when another care provider is not present to perform an independent double
check of a high alert medication, the provider administering the medication is to perform a
second verification immediately prior to medication administration per the procedures spelled out
above in all sites of care.
1. Anesthesiologists and clinical staff of the Anesthesia Department will follow Anesthesia
Departmental policy regarding the administration of medications.

2. The labels are verified both verbally and visually by two individuals (at least one must be a
licensed or certified professional) when the person preparing the medication is not the person
administering it to the patient. See Hospital Administrative policy 7.80-Medication and Solution
3. In circumstances when another care provider is not present to perform an independent double
check of a high alert medication, the provider administering the medication is to perform a
second verification immediately prior to medication administration per the procedures spelled out
above for all sites of care.

Related policies and procedures that must be followed in conjunction with this policy include:

IV Administration Guidelines (Adults and Pediatrics) located on UConnect.
Hospital Administrative policy 7.80-Medication and Solution Labeling
Hospital Administrative policy 8.17-Administration of Medications
Hospital Administrative policy 8.31-Guidelines for Hospital Location Specific Administration of IV Medications
Hospital Administrative policy 8.58-ntrathecal Chemotherapy Ordering, Administration and Documentation
Hospital Administrative policy 8.59-Chemotherapy Processes: Informed Consent, Ordering, Verification,
Administration, Documentation and Patient/Family Education
Hospital Administrative policy 8.92-Epidural and Intrathecal Analgesia
Nursing Departmental Patient Care policy 1.17-IV Patient Controlled Analgesia (PCA)
Nursing Departmental Administrative policy 10.13-Chemotherapy Administration
Nursing Departmental Patient Care policy 10.14-Access to Intrathecal Reservoirs and Administration of Medications
including Chemotherapeutic Agents
Nursing Departmental Patient Care policy 10.17-Chemotherapy Administration through a Nephrostomy Tube
Pharmacy Departmental policy 10.15-Medication Distribution System


Sr. Management Sponsor: VP, Professional Services
Author: Director of Pharmacy

Review/Approval Committee(s): Medication Safety Committee; Nursing Executive Council; Pharmacy and
Therapeutics Committee; UW Health Clinical Policy Committee


Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee