A Self-Assessment Guide for Health Care Organizations - IFC

Standard PS.3 [High alert medications]
The organization develops an approach to improve the safety of high-alert medications.
Intent of PS.3
When medications are part of a patient treatment plan, appropriate management is critical to ensuring patient safety. A frequently cited
medication safety issue is the unintentional administration of concentrated electrolytes (e.g. potassium chloride [2mEq/ml or more
concentrated], potassium phosphate, sodium chloride [0.9% or more concentrated], and magnesium sulfate [50% or more concentrated]).
This error can occur when a staff member has not been properly oriented to the patient care unit, when contract nurses are used and not
properly oriented, or during emergencies. The most effective means to reduce or eliminate this occurrence is to remove the concentrated
electrolytes from the patient care unit to the pharmacy. The organization collaboratively develops a policy and/or procedure that prevents the
location of concentrated electrolytes in patient care areas where misadministration can occur. The policy and/or procedure specifies any areas
where concentrated electrolytes are clinically necessary (such as the emergency department or operating theater); how they are clearly labeled;
and how they are stored in those areas in a manner that restricts access to prevent inadvertent administration.
Measurable Element Look for Score Observations
What is required
1) A collaborative process
is used to develop policies
and/or procedures that
address the location,
labeling, and storage of
concentrated electrolytes.
2) Concentrated
electrolytes are not present
in patient care units unless
clinically necessary. Actions
are taken to prevent
inadvertent administration
in those areas where
permitted by policy.
How is this element
assessed
Physicians, nurses and other health
care workers work together to
write and implement policies and
procedures to deal with
concentrated electrolytes. Review
minutes of meetings and talk with
staff members regarding their
involvement.
Make observations during safety
rounds to ensure that concentrated
electrolytes are not kept on the
units, except where policy permits.
In these permitted areas (e.g.
emergency department, ICU) check
that they are properly stored and
labeled.
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58 IFC Self-Assessment Guide for Health Care Organizations