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Medication Safety – High Alert and Hazardous Medication

The Joint Commission requires organizations to identify, in writing, high-alert and hazardous medications available and follow a process for managing such medication. Does posting a list of these types of medications printed from the internet meet the intent of these requirements ?

Any examples are for illustrative purposes only.

No. Simply posting a list of high-alert and hazardous medication printed off the internet does not meet the intent of the requirements found at MM.01.01.03.  While review of such a list assists in identifying medications known to have a heightened risk of causing harm, organizations need to have a process that identifies which medications on such a list indicate those medications that are available within the organization.
When developing a list, the following should be evaluated:
  • Medication utilization patterns that may be unique to the organization
  • Internal data about medication errors, sentinel events, known safety issues, etc.
Information available from sources, such as:
  • The medication manufacturer
  • State pharmacy boards
  • Regulatory agencies, such as the CDC, FDA, OSHA, USP, etc.
  • Institute for Safe Medication Practices, (ISMP) and other professional resources
  • Applicable law and regulation
  • Services provided and patient population served
The organization determines where and how the list of medications is documented and made available to practitioners/staff involved in medication ordering, management and administration practices. Examples may include, but not limited to:
  • Indicating on a pre-populated list obtained from an external source which medications are available for administration
  • Developing separate lists for medications identified as high-alert and/or hazardous

Organizations determine how staff and practitioners will be educated regarding processes for managing these medications.

Additional Resources
ASHP Center on Medication Safety and Quality
Institute for Safe Medication Practices (ISMP)
Manual: Hospital and Hospital Clinics
Chapter: Medication Management MM
First published date: February 08, 2019 This Standards FAQ was first published on this date.
This page was last updated on October 21, 2021

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