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)
 
Last updated on September 16, 2020
Manual: Behavioral Health
Chapter: Medication Management MM

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