Page 84 - Registrar Orientation Manual 2016

Medicine/medicine group
Some risks of potential harm to the patient
Can be caused by
Anticoagulants
• Bleeding • Blood clot • Death
• Under or over dosing
• Interactions with food, other medicines,
herbal products
• Confusion between tablet strengths
• Inappropriate monitoring
Opioids
• Constipation
• Nausea and vomiting
• Over sedation
• Respiratory depression
• Death
• Anti-emetics and laxatives not prescribed when appropriate
• Overdose, either absolute or relative (dose not decreased to account for renal impairment)
• Wrong product prescribed, dispensed and/or administered
• Inappropriate monitoring
Insulin
• Hypoglycaemia • Hyperglycaemia • Death
• Wrong dose
• Wrong product prescribed, dispensed
and/or administered
• Inappropriate monitoring
Concentrated potassium injection
• Arrhythmia • Death
• Bolus administration
• Wrong product selection
Oral methotrexate
• Liver failure
• Bone marrow suppression • Death
• Wrong dose – once weekly dose prescribed, dispensed or mistakenly taken daily
• Lack of monitoring
Want to learn more?
Institute for Safe Medication Practices (ISMP). ISMP’s List of High-Alert Medications. 2012. Available at http://www.ismp.org/Tools/highalertmedications.pdf.
Institute for Healthcare Improvement (IHI). 2012. How to Guide: Prevent Harm from High-risk Medications. IHI, Cambridge, MA. Available at www.ihi.org.
Health Quality and Safety Commission. Medication Alerts. Available at www.hqsc.govt.nz/assets/Medication-Safety/Alerts-PR.
National Health Service (NHS). 2008. The How-to-Guide for Reducing Harm from High-risk Medicines.
Available at www.patientsafety rst.nhs.uk/ashx/Asset.ashx?path=/How-to-guides-2008-09-19/Medicines%201.1_17Sept08.pdf.
The Health Quality & Safety Commission has developed a series of activities designed for individuals or organisations to look at the system for managing high-risk medicines. Take one step to help prevent harm from high-risk medicines – available on the Open for better care website at http://open.hqsc.govt.nz/medication/one-step.
National Patient Safety Campaign
www.open.hqsc.govt.nz