Preventing harm from high-alert medications

Jt Comm J Qual Patient Saf. 2007 Sep;33(9):537-42. doi: 10.1016/s1553-7250(07)33057-2.


Background: One of the 12 interventions that the Institute for Healthcare Improvement (IHI) recommends for its 5 Million Lives Campaign is "Prevent Harm from High-Alert Medications . . . starting with a focus on anticoagulants, sedatives, narcotics, and insulin." EXECUTING SYSTEM-LEVEL CHANGES: Three essential elements are needed to execute system-level changes in an organization: will, ideas, and execution. Will is developed by examining the status quo in an organization and agreeing that it is no longer acceptable. Ideas-changes that will make the system safer-can be found in the literature and in the experience of other hospitals and are the basis for the recommended general interventions to reduce errors and harm associated with high-alert medications. Execution, the process of making those changes real, requires commitment from senior leaders and clinical leaders, along with the organizational capacity to improve. The steps in the medication system are so interrelated that a change in one area will affect others' ability to complete their work. In addition, senior leadership and clinical leadership must visibly support the effort, connecting the reduction in high-alert medication-related harm to the overall hospital goal of harm reduction is essential.

Conclusion: The campaign's goal is to achieve a 50% reduction in harm related to high-alert medications. Employing strategies such as standardization and simplification will provide the foundation for improved medication safety.

MeSH terms

  • Harm Reduction*
  • Humans
  • Medication Errors / prevention & control*
  • Medication Systems, Hospital / organization & administration
  • Organizational Objectives
  • Quality Assurance, Health Care / organization & administration
  • Safety Management / methods*
  • United States