Policy Manual sample

MDT Home Health Care Agency, Inc. HIGH ALERT MEDICATION MANAGEMENT POLICY: It is the policy of the Agency to maintain a list of high alert medications that require specific safeguards to reduce the risk of errors related to ordering and prescribing, transcribing, preparation, storage, distribution and administration. The Director of Nursing, Clinical Manager is responsible for this standard. High alert medications are drugs that have an increased risk of causing significant harm to a patient when used in error. Because the consequences of an error associated with use of these medications can result in significant patient injury, special precautions will be employed with their overall management throughout the institution. PROCEDURE: The following are categories of medications and specific medications that require special precautions in handling during all phases of medication management processes, which may include, but are not limited to: • Narcotics/opiates • Insulin • Warfarin High Alert Medication Processes: * Narcotics: • Implement standardized protocols for the initiation and maintenance of pain management. • Routine monitoring of vital signs, pain scale, and adverse effects of narcotics. • Program pumps with an independent double check. • Limit strengths available * Insulin: • Implement diabetes management flow sheet. • Coordinate meals and insulin administration times, as appropriate. • Independent double checks. • Separate look-alike, sound alike insulin and highlight differences. • Never use “U” to abbreviate “units” * Warfarin: • Limit number of tablet strengths available • Implement standardized protocols for dosing and monitoring. • Patient education is a critical component of warfarin use. PROCEDURE: (Also when we provide staffing to any in-patient facility) The following are categories of medications and specific medications that require special precautions in handling during all phases of medication management processes, which may include, but are not limited to, reducing staff access to these medications; using auxiliary labels; using automated alerts on all patient care standardizing the preparation and administration of these products; and employing automated or independent double checks when necessary: High Alert Drug Categories: Þ IV Adrenergic agonists (i.e., epinephrine) Þ IV Adrenergic antagonists (i.e., propranolol) Þ Inhaled and IV Anesthetic agents (i.e., propofol) Þ Cardioplegic solutions (hypothermic and hyperkalemic solutions administered to the myocardium during cardiac surgery) Þ Chemotherapeutic agents Þ Hypertonic Dextrose (20% or greater) Þ Dialysis solutions Home Health Agency Nursing Care & Procedures K-205