acute care hospital

n 2013, ISMP conducted a survey on bullying, incivility, intimidation, and other forms of disrespectful behavior. These behaviors have run rampant in healthcare while

many remain silent or make excuses to minimize the profound devastation that disrespectful behavior leaves in its wake. These behaviors range from overt acts of abuse and bad behavior to insid- ious actions so embedded in our cul- ture that they seem normal—gossip, for example. Any behavior that influences the willingness of staff or patients to speak up or interact with an individual because he or she expects the encounter will be unpleasant or uncomfortable, fits the definition of disrespectful behavior.1 See Table 1 on our website (www.ismp. org/sc?id=352) for exam- ples of disrespectful behavior.

In our October 2013 newsletter (www.ismp. org/sc?id=353), we pub- lished the results of our survey (Part I), which clearly exposed healthcare’s con- tinued tolerance of and indifference to disrespectful behavior. Despite more than a decade of emphasis on safety, little improvement has been made. Widespread disrespectful behaviors in healthcare persist unchecked and are found at all levels of the organization and among all disciplines of staff. The stubborn strength of this problem lies in its quiet ability to undermine critical conversations.1 In Part II, we delve into the impact of disrespectful behaviors, why they arise and persist, and how to address them.

Impact of disrespectful behaviors Disrespectful behaviors chill commu- nication and collaboration, undercut individual contributions to care, under- mine staff morale, increase staff resig-

nations and absenteeism, create an unhealthy or hostile work environ- ment, cause some to abandon their profession, and ultimately harm patients. These behaviors have been linked to adverse events, medical errors, compromises in patient safety, and even patient mortality.2,3 Dis- respect causes the recipient to experi- ence fear, anger, shame, confusion, uncertainty, isolation, self-doubt, depression, and a whole host of physi- cal ailments such as insomnia, fatigue, nausea, and hypertension.4 These feel- ings diminish a person’s ability to think

clearly, make sound judgments, and speak up regarding ques- tions or concerns. Dis- respectful behavior is also at the root of difficulties encountered in develop- ing team-based approach- es to improving care.4 Patient confidence has

also been undermined by disrespectful behaviors, making

patients less likely to ask questions or provide important information.

Why disrespectful behaviors arise Disrespectful behaviors can arise in any healthcare setting, and both the stressful nature of the environment and human nature play roles in this destructive behavior. Human beings are wired for survival. We are driven to function in “survival” mode when forced to cope with difficult personal frustrations and system failures. Disrespectful behavior is often “sur- vival” behavior gone awry.1 Although personal frustrations and system fail- ures do not excuse disrespectful behav- ior, they often create a tipping point by which an individual is pushed over the edge into full-blown disrespectful behavior. Characteristics of the individ- ual, such as insecurity, anxiety, depres-

Part II: Disrespectful behaviors Their impact, why they arise and persist, and how to address them

continued on page 2—Behaviors

The stubborn

strength of dis- respect lies in its

quiet ability to un- dermine critical

conversa- tions.1

NurseAdvise-ERR Medication Safety Alert!

Educating the healthcare community about safe medication practices May 2014 Volume 12 Issue 5

â

â

Supported by educational grants from Baxter and BD

Auvi-Q post injection ticking sound. There’s something impor-

tant to know about the AUVI-Q auto- injector (EPINEPHrine injection), which uses digital voice instructions to “talk” people through the injection process (Figure 1). The device has LED light cues that flash green during injection and red after the device has been used. Prior to injection, Auvi-Q must be re- moved from its case and the needle guard must be pulled off (view the Auvi- Q demonstration at: www.auvi-q.com/ auvi-q-demo). The device will make a

distinct click and hiss sound when acti- vated. Accord- ing to the package insert, the base that houses the needle will lock in place after injection so it can’t be reused. The voice instruc- tion system will continue to re-

mind the user that the Auvi-Q has been

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Figure 1. Auvi-Q must be replaced in its case prior to disposal to prevent ticking sounds as the battery dies.

Help ISMP update its latest high-alert drug list It’s been more than 2 years since we last sur- veyed readers and updated ISMP’s List of High-Alert Medications. Please take a few minutes to complete our short survey by June 20, 2014, at: www.ismp.org/sc?id=358. A copy of the survey appears on pages 6 and 7. We would like to know whether YOU believe the medications in the survey belong on our high- alert medication list and whether YOUR PRACTICE SITE considers them to be high- alert medications with special precautions in place. We are also interested in your opinion regarding medications that should be added to ISMP’s list. We appreciate your participation!

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sion, aggressiveness, and narcissism, can also kick in and serve as a form of self-protection against feelings of inad- equacy.4 Cultural, generational, gender biases, and current events influencing mood, attitude, and actions, also con- tribute to disrespectful behavior.3 Practitioner impairment, including substance abuse, mental illness, or personality disorder, is often at the root of highly disruptive behavior.3

Differences in communication styles and power dynamics can also play a role.4,5 For example, physicians may get frustrated when nurses present infor- mation in more detail than they believe is necessary. Nurses may get frustrated when physicians do not seem interest- ed in the information provided. These differences in communication styles can lead to disrespectful behaviors. The hierarchical nature of healthcare and a sense of privilege and status can lead those at the top of a hierarchy to treat others lower on the hierarchy with disrespect. A sense of autonomy can also underlie passive disrespect, such as a resistance to collaborate with others or follow procedures that pro- mote safety. Unfortunately, the victims of disrespectful behavior may feel they have no choice but to become perpe- trators themselves.4 They don’t quite know how to get their arms around the problem, so they tolerate the behavior or simply join in.

Why disrespectful behaviors persist Healthcare organizations have perpet- uated the problem of disrespectful behavior for years by ignoring it, there- by tacitly accepting such behaviors.1 The healthcare culture has permitted a certain degree of disrespect and “aggressive crudity” while considering this a normal style of communication.4 Studies have shown that disrespectful behaviors are tolerated most often in unfavorable work environments, but it is unclear whether poor working con- ditions create an environment where the behaviors are tolerated, or if the disrespectful behaviors create the unfavorable environment.6,7

Organizations have largely failed to address disrespectful behavior for a variety of reasons. First, the behavior typically occurs daily but often goes unreported due to fear of retaliation and the stigma associated with “whis- tle blowing.” Disrespectful behaviors are difficult to measure, so without robust systems of environmental scan- ning to uncover the behavior, leaders may be ignorant of the problem.8 Leaders may also be unaware of the behavior if managers shield them from this information because they view it as a personal failure.8 If disrespectful behaviors are known, leaders may be reluctant to confront individuals if they are powerful or high-revenue produc- ers, or they may not know how to han- dle the problem. It’s not a topic taught in training programs, so leaders may hesitate to take on a problem for which there is no obvious solution.8

Regardless of the reasons for disre- spectful behavior, none justify inac- tion. According to our 2013 survey, only a quarter of the respondents felt their organization dealt effectively with disrespectful behavior. The deep sense of frustration threaded through the survey comments suggest that the time to act is now.

Addressing disrespectful behavior I. Set the stage Establish a steering committee of trustees, senior leaders, middle man- agers, physicians, pharmacists, nurs- es, and other staff. Have the commit- tee educate itself about disrespectful behavior, define the behavior, list examples of the many forms it can take, and establish an action plan that specifies how to identify disre- spectful behavior, respond to it, and measure the success of organization- al efforts. Responsibility for address- ing the problem belongs to the lead- ers, who need to raise awareness of the problem, inspire others to change, communicate respect as a core value, articulate their commit- ment to achieving it, and create a sense of urgency around doing so.

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used, and its LED lights will continue to blink red until the cover is put back on or until the battery eventually runs out. If the cover is not replaced on the device, the electronic voice speaker makes a “ticking” sound as the battery drains and can’t fully power the device. This sound might alarm someone who thinks the ticking noise is associated with a possi- ble calamitous event. Emergency depart- ment staff alerted us to this issue after the family of a patient who used an Auvi- Q auto-injector brought it in without the case. Staff later heard a ticking sound coming from a needle disposal box where the device had been discarded. We can assume that many patients and healthcare staff will not replace the de- vice back into the case after emergency use. Therefore, remind staff that the cover needs to be replaced or the device will emit a ticking sound as the battery dies. We have notified the companies about this ticking sound, which may cause staff to call security if the source of the ticking noise is not realized.

Close call with wintergreen oil. The Drug Facts label on bot-

tles of wintergreen oil (methyl salicylate) (Figure 1) indicates that it is used for “temporary relief of muscular aches and pains due to overexertion or fatigue.”

When a hospi- tal set up its new computer system, this product was available on the formulary. However, the primary hospi- tal formulary indication did not match the Drug Facts label. The prod- uct is actually used by surgi- cal staff for ap- plication to

their paper face masks to make surgical smells less noxious, such as during bowel surgeries. When building the

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Figure 1. This small bottle of wintergreen oil can harm a patient if taken orally.

Join ISMP in celebrating National Nurses WeekMay 6 - 12, 2014

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Establish a “no retribution” policy for those who report disrespectful behav- ior. This policy must be established at the very onset of organizational efforts to reduce disrespectful behaviors.

Open the dialogue about disrespect- ful behavior by surveying staff about the issue using surveys from ISMP (www.ismp.org/survey/disrespectful), the Agency for Healthcare Research and Quality (www.ismp.org/sc?id =343), or Rosenstein and O’Daniel2 as templates. Incorporate questions about disrespectful behaviors in safe- ty rounds. Hold focus groups where frank discussions can be held with objective facilitators to keep the con- versation productive. However un- comfortable, dialogue on this issue is crucial to the development of more effective and respectful ways of inter- acting with each other.

II. Establish a code of conduct Create a code of conduct (or code of professionalism) that serves as a mod- el of interdisciplinary collegial rela- tionships (different but equal) and collaboration (mutual trust and respect that produces willing coopera- tion).9 Clearly articulate the standard of behavior desired as well as unac- ceptable behaviors—don’t assume staff know this, so be clear.8 Another crucial factor to consider—all staff must believe in the code of conduct. Addressing disrespectful behavior must start with an absolute belief by all staff that no one deserves to be treated with disrespect, even in the wake of an error. Furthermore, the code of conduct should not allow any exemptions. As long as those who gen- erate the most revenue are excused from responsibility for their actions, the code of conduct will have little impact on anyone else’s behavior.10

III. Establish a communication strategy Establish a standard, assertive com- munication process for healthcare staff who must convey important information. Stating the problem along with its rationale and a poten- tial solution can improve assertive

communication. Numerous com- munication techniques are available to help staff accomplish this, includ- ing:

1. SBAR (www.ismp.org/sc?id=344): the person communicating the crucial information covers the Situation, Background, Assess- ment, and Recommendations

2. D-E-S-C script (www.ismp.org/ sc?id=345): Describe in objective terms what you observed, heard, or perceived; Express concerns using “I” statements and non- judgmental terminology; Specify or inquire about an alternate course of action; discuss both pos- itive and negative Consequences

3. TeamSTEPPS (http://teamstepps. ahrq.gov/): Team Strategies and Tools to Enhance Performance and Patient Safety, an evidence- based teamwork system to improve communication and teamwork skills among health- care professionals

A 2010 study also offers insight into key skills used by nurses who have verbalized issues that have previous- ly been out of the realm of discus- sion.11 These skills include explain- ing your positive intent and how you want to help both the caregiver and patient, using facts and data as much as possible to support your concern, avoiding frustration and anger, and other actions that are summarized in Table 2 on our web- site (www.ismp.org/sc?id=352). The study also found that these skills were not enough—it took extraordi- nary courage to speak up because the nurses often believed they were violating norms, accepted practice, and rules.

IV. Manage conflicts An escalation policy must be estab- lished to manage conflicts about the safety of an order when the standard communication process fails to

Behaviors continued from page 2

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process for the new computer system, it was not recognized that this product should not be available for ordering by the prescriber, so it was added to the order entry system without limits on the dose, route, or frequency. A prescriber found the product on the drug list and ordered it to be used at the patient’s bedside as an air freshener. Directions were provided by the prescriber using the comment field of the order entry screen. A bottle of wintergreen oil was dispensed and placed in the patient’s room. The concentration of this product is 89% and it comes in a small (59 mL) bottle. Since the bottle is so small, this could easily be mistaken as an oral unit dose liquid. Fortunately, the product was not used inappropriately and it did not result in patient harm. However, we have had a number of other incidents where other topical products left at the bedside were swallowed by a confused patient. Ensuring safe use of this prod- uct requires intervention. Hospitals should either remove the product from use or limit areas where it is available. Air fresheners from environmental serv- ices in spray form are generally available for use in patient rooms. This product should not be included as an option on computerized order entry systems. If it is stocked in the pharmacy, where it may be used as an ingredient for compound- ing topical products, it should be segre- gated from items that may be dispensed to patient care areas. This product can be purchased without a prescription and may also pose risks at other practice sites and in a patient's home.

Use of “NoAC” abbreviation. A pharmacy student on a hospital

internal medicine rotation had a patient admitted to the coronary care unit (CCU) with atrial fibrillation. The patient had been taking warfarin prior to hospi- talization. A new order was written for amiodarone for the arrhythmia, but this drug can interact with warfarin and en- hance its anticoagulation effect. Upon review of the patient’s medical record, the student and other team members saw a cardiology note that stated, “Pa-

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Free customized medication safety alerts for consumers and caregivers. Details at: www.consumermedsafety.org.

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resolve an issue (www.ismp.org/sc?id =346). Staff must know who to call to aid in getting a satisfactory resolution. Be sure the process provides an avenue for resolution outside the typ- ical chain of command in case the conflict involves a subordinate and his/her supervisor.

Following a Two Challenge Rule is one option. Used in highly reliable indus- tries with excellent safety records, the rule requires communication of criti- cal information twice to the same per- son. If there’s no resolution, the mat- ter is referred to at least one other per- son before a final decision is made. Another option is a tool from aviation, the Most Conservative Response Rule (MCRR). In the event of an impasse, this technique suggests that involved staff accept the most conservative (and safest) option being considered.

If a concern is not addressed, staff need a clear and immediate process to take the matter to another or refer it to a timely ad hoc group for peer review. If the patient’s condition requires immediate attention, a rapid response team can be called if available.

V. Establish interventions Develop an intervention policy that has full leadership support to consis- tently address disrespectful behav- iors. An effective policy includes zero tolerance for disrespectful behaviors regardless of the offender’s standing in the organization, fairness to all par- ties, consistency in enforcement, a tiered response to infractions, a restorative process to help people change their behavior, and surveil- lance mechanisms.10,12 Levels of interventions might start with coach- ing and proceed to progressive disci- pline as warranted. An intervention policy needs to clearly articulate the behaviors or repeated behaviors that will be referred for disciplinary action, and how and when the disciplinary process will start.13 The focus of an intervention must be on building trust and holding staff accountable for making better behavioral choices.

The importance of a prompt, pre- dictable, and appropriate response to an alleged violation cannot be overemphasized.10 In all cases, those who report or cooperate in the inves- tigation needs to be protected against retaliation.14

The intervention policy should also require addressing any system issues that amplify and perpetuate the disre- spectful behavior. Common system problems include issues that affect workloads, staffing, budgeting, educa- tion, communication, handoffs, phys- ical hazards, and environmental stres- sors. Individual behaviors can also be altered through system improve- ments.1

VI. Train staff Provide mandatory hospital-wide education for all staff about the impact of disrespectful behavior and appropriate professional behavior as defined by the code of conduct.13,15 Provide skill-based training in com- munication methods, relationship building, business etiquette, behav- ioral techniques to confront and address disrespect, conflict resolu- tion, assertiveness training, team training, and how to report disre- spectful behaviors. Use role-playing, vignettes, or aggression scenarios to strengthen skills associated with assertive communication, conflict resolution, and interpersonal interac- tions. One health system provides leaders with a toolkit that includes talking points regarding the impact of disrespectful behavior, the code of conduct, definitions, surveys, com- munication/teamwork guides, key articles and intranet resources, “no retribution” policy, and a letter from the chief executive officer outlining full leadership support.8

VII. Encourage reporting/surveillance Implement a confidential reporting/ surveillance program for detecting disruptive behavior and measuring compliance with the code of con- duct. A formal reporting program and

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tient is taking Coumadin and was placed on amiodarone. There is an in- teraction. Instead of adjusting the Coumadin dose, consider NoAC." The entire medical team, the pharmacy pre- ceptor, and the student, all assumed that this meant “Due to the potential in- teraction between warfarin and amio- darone, consider using no anticoag- ulation (discontinue the warfarin).” The cardiologist was contacted to confirm this interpretation. To everyone’s sur- prise, the physician said he was actu- ally using the abbreviation “NoAC” instead of writing out the words “new (or novel) oral anticoagulant.” He meant that instead of warfarin, one of the direct thrombin inhibitors, such as dabigatran, should be considered. A quick search of the Internet revealed frequent use of the abbreviation “NoAC,” and its use has become more popular with the introduction of the newer anti- coagulants. We’ll be adding “NoAC” to our “do not use” list of potentially dan- gerous abbreviations and strongly sug- gest cautioning providers not to use it clinically. It should be noted that drug interactions can occur between amio- darone and direct thrombin inhibitors, decreasing clearance and thus increas- ing plasma levels of the anticoagulant. Still, the dabigatran label does not recom- mend a dosage adjustment (www.ismp. org/sc?id=281) although it is probably wise to use the drugs together with cau- tion until more is learned. The apixaban label recommends a dose reduction to 2.5 mg or to avoid concomitant use (www.ismp.org/sc?id=282), and the ri- varoxaban label states that combined use should be avoided (www.ismp.org/ sc?id=283).

Cardizem-Cardene mix-up. An emergency department (ED) nurse

prepared and administered a CARDENE (niCARdipine) infusion instead of the prescribed CARDIZEM (diltiazem) infu- sion. The patient received the wrong medication for several hours before the mistake was discovered. The patient be- came hypotensive during the infusion, but he was quickly treated so there was

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Free customized medication safety alerts for consumers and caregivers. Details at: www.consumermedsafety.org.

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no permanent harm and no further medication management required. In another reported mix-up with these drugs, a nurse programmed a smart pump to infuse Cardizem instead of Cardene. The patient received the cor- rect medication but at the wrong rate until the mistake was caught by a nurse on the next shift. Again, no harm was reported. In an earlier case in which a mix-up occurred in the pharmacy at the time of dispensing, Cardizem was sent instead of Cardene, and a nurse later assumed this was an intentional phar- macy substitution and did not question the change. Recommendations for pre- venting drug name mix-ups like these can be found in our August 9, 2007, acute care newsletter (www.ismp.org/ sc?id=269). The two drugs are not on our list of commonly confused drug names maintained by ISMP, so we will be adding the pair.

safetywires cont’d from page 4an informal process for unwritten reports need to be offered. Encourage anyone who experiences or witnesses disruptive behavior to report the event.14 The “no retribution” policy for reporting should be well known to staff and upheld. Provide periodic updates to reporters that discuss how disrespectful behaviors are being addressed, but details about individu- als should remain confidential.

No organization should assume that the absence of reports of disrespect- ful behavior means it is not occur- ring. Other means of surveillance to identify disrespectful behaviors need to be employed, including feedback from patients and families, staff and patient surveys, focus groups, informal dialogue, peer and team evaluations, and making direct inquiries at routine intervals (e.g., during safety rounds). Surveys appear to be the most reliable sur- veillance tool.2

VIII. Create a positive environment Certain aspects of the workplace environment are key to combatting disrespect, including a fair and Just Culture, respectful management of serious adverse events, and trans- parency so staff feel safe talking about disrespectful behavior with- out fear of reprisal.13 Another factor is visible leadership commitment to a respectful culture, which requires leading by example. Leaders should set the tone with an attitude of mutual respect for the contributions of all staff, remain open to questions and new ideas, and reward outstand- ing examples of collaborative team- work, respectful communication, and positive interpersonal skills. Using key communication tools such as email blasts, leaders can

maintain an ongoing dialogue about respectful behaviors with the entire organization to help assure staff that leadership commitment to a respectful culture is not fleeting.1

References 1) Zimmerman T, Amori G. The silent organiza- tional pathology of insidious intimidation. J Healthc Risk Manag. 2011;30(3):5-6,8-15. 2) Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-71. 3) McNamara SA. Incivility in nursing: unsafe nurse, unsafe patients. AORN J. 2012;95(4):535-40. 4) Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845-52. 5) Gessler R, Rosenstein A, Ferron L. How to handle disruptive physician behavior. Am Nurse Today. 2012;7(11):8-10. 6) Lamontagne C. Intimidation: a concept analy- sis. Nurs Forum. 2010;45(1):54-65. 7) Budin WC, Brewer CS, Chao YY, et al. Verbal abuse from nurse colleagues and work environment of early career registered nurses. J Nurs Scholarsh. 2013;45(3):308-16. 8) Porto G, Deen J. Drawing the line. Effective management strategies for disruptive behavior. Patient Saf and Qual Healthcare. November/ December 2008:20-4,26-8. 9) Kramer M, Schmalenberg C. Securing “good” nurse physician relationships. Nurs Manage. 2003; 34(7):34-8. 10) Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-8. 11) Maxfield D, Grenny J, Lavandero R, et al. The silent treatment. Why safety tools and checklists aren’t enough to save lives. VitalSmarts, AORN, & AACN. September/October 2011. www.aacn.org/ wd/hwe/docs/the-silent-treatment.pdf 12) American Nurses Association. Tip cards: Bullying in the workplace. www.ismp.org/sc?id =347 13) Pennsylvania Patient Safety Authority. Chain of command: when disruptive behavior affects com- munication and teamwork. Pa Patient Saf Advis. 2010;16(7)[Suppl 2]:4-13. 14) DuPree E, Anderson R, McEvoy MD, et al. Professionalism: a necessary ingredient in a culture of safety. Jt Comm J Qual Patient Saf. 2011;37(10): 447-55. 15) The Joint Commission. Behaviors that under- mine a culture of safety. Sentinel Event Alert. 2008;40:1-3.

Special Announcements

ISMP webinar Join us for our May 28webinar, Manag- ing Outcomes and Enhancing Safety: The Role of Protocol-Driven Care in Today’s Healthcare Environment. Join our guest speakers as they discuss proto- col-driven care for treatment modalities such as pain management, nutritional sup- port, and various drug therapies. For details, visit: www.ismp.org/sc?id=349.

Unique 2-day program Attend ISMP’s Medication Safety INTEN- SIVEworkshop in Las Vegas on May 30- 31. This workshop provides hands-on experiences with event investigation, risk analysis, error-reduction strategies, action planning, Just Culture, and more! For details, visit: www.ismp.org/sc?id=351.

ISMP Medication Safety Alert! Nurse Advise-ERR (ISSN 1550-6304) ©2014 Institute for Safe Med- ication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal newsletters or communications. Other reproduction is prohibited without written permission. Unless noted, published errors were received through the ISMP National Medication Errors Reporting Pro- gram (ISMP MERP). Editors:Ann Shastay, RN, MSN, AOCN; Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Hor- sham, PA 19044-2321. Tel.: 215-947-7797; Fax: 215-914-1492; EMAIL: [email protected].

Report medication errors to ISMP by going to: www.ismp.org/MERP.

Behavior is a mirror in which

everyone displays his own image.

—Johann Wolfgang Von Goethe

tothepoint

Please complete our short survey on high-alert medications in hospitals and other inpatient healthcare settings, and submit your responses by June 20, 2014, at: www.ismp.org/sc?id=358. High-alert medications bear a heightened risk of causing significant patient harm when they are used in error. Although errors may or may not be more common with these medications, the consequences of an error are often devastating to both patients and their healthcare providers.

For Section A, indicate whether YOU consider these drugs or drug classes to be high-alert medications. For Section B, indicate whether YOUR PRACTICE SITE considers these drugs to be high-alert medications. For Section C, please indicate whether you believe your practice site has SPECIAL PRECAUTIONS IN PLACE for these medica- tions, and whether you believe they are EFFECTIVE. Under OTHERS, include additional medications that YOU and/or YOUR PRACTICE SITE consider high-alert medica- tions. There will be ample room to make comments when you enter your responses at the above URL.

ISMP Survey on High-Alert Medications in Hospitals and Other Inpatient Healthcare Settings

Medication or Class of Medications Section A Section B Section C

Do YOU consider this a high-alert drug?

Does YOUR PRACTICE SITE consider this a high-alert drug?

Does YOUR PRACTICE SITE have special pre- cautions in place?

Do YOU believe your practice site’s precautions are EFFECTIVE?

Current List (Drug Classes or Specific Drugs) Yes No Yes No Yes No Yes No 1) Adrenergic agonists, IV (e.g., EPINEPHrine, terbutaline, norepinephrine) 2) Beta-adrenergic antagonists, IV (e.g., propranolol, metoprolol) 3) Anesthetic agents, general, inhaled, IV (e.g., propofol, ketamine) 4) Antiarrhythmics, IV (e.g., amiodarone) 5) Antithrombotic agents

Anticoagulants (e.g., warfarin, heparin) 6) Factor Xa inhibitors (e.g., fondaparinux, apixaban, riveroxaban) 7) Direct thrombin inhibitors (e.g., dabigatran, argatroban, lepirudin) 8) Thrombolytics (e.g., alteplase, tenecteplase) 9) Glycoprotein IIb/ IIIa inhibitors (e.g., eptifibatide) 10) Cardioplegia solution 11) Chemotherapeutic agents, parenteral and oral 12) Dextrose, hypertonic, 20% or greater 13) Dialysis solutions, peritoneal and hemodialysis 14) Epidural or intrathecal medications 15) Hypoglycemics, oral 16) Inotropic medications, IV (e.g., digoxin) 17) Liposomal forms of drugs and conventional counterparts 18) Moderate sedation agents, IV (e.g., midazolam) 19) Moderate sedation agents, oral, for children (e.g., midazolam) 20) Opioids, injectable (IM, IV) 21) Opioids, transdermal 22) Opioids, transmucosal and oral, including liquid concentrates and

immediate- or sustained-release products 23) Neuromuscular blocking agents (e.g., succinylcholine, rocuronium) 24) Parenteral nutrition preparations 25) Radiocontrast agents, IV 26) Sterile water for injection, inhalation, and irrigation, in containers of 100

mL or more (excluding pour bottles) 27) Sodium chloride for injection, hypertonic, greater than 0.9% concentration 28) Epoprostenol (Flolan), IV 29) Magnesium sulfate injection 30) Methotrexate, oral, non-oncologic use 31) Opium tincture 32) Oxytocin, IV 33) Insulin, subcutaneous (including use in pen devices and pump devices) 34) Insulin, IV 35) Nitroprusside sodium, IV

continued on page 7—Survey

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Please encourage your patients and staff to visit www.consumermedsafety.org often. It may save a life!

Please select the categories that best describe your profession (select one), current position (select one), and work setting (select all that apply).

Profession: Pharmacy technician Pharmacist Registered nurse Practical nurse Nurse practitioner Physician Physician assistant Other:_________________

Position: � Staff Manager/Director � Administrator � Other:______________________

Work setting: Inpatient: oncology � Inpatient: critical care � Inpatient: non-critical care � Inpatient: other_________________ � Outpatient: oncology � Outpatient: critical care � Outpatient: non-critical care � Outpatient: other________________

Thank you for particpating! Enter your responses by June 20, 2014, at: www.ismp.org/sc?id=358.

Medication or Class of Medications Section A Section B Section C

Do YOU consider this a high-alert drug?

Does YOUR PRACTICE SITE consider this a high-alert drug?

Does YOUR PRACTICE SITE have special pre- cautions in place?

Do YOU believe your practice site’s precautions are EFFECTIVE?

Current List (Drug Classes or Specific Drugs) Yes No Yes No Yes No Yes No

36) Potassium chloride injection concentrate 37) Potassium phosphate injection 38) Promethazine, IV 39) Vasopressin, IV or intraosseous New Drugs to Consider (Not on ISMP’s List of High-Alert Medications) 40) Insulin, U-500, special emphasis, listed separate from U-100 insulin 41) Antithrombotic agents

Antiplatelet agents (e.g., clopidogrel [Plavix], cilostazol [Pletal]) 42) Ergot derivatives (e.g., methylergonovine, dihydroergotamine) 43) Methylergonovine (without other ergot derivatives) 44) Medications administered via an endotracheal tube 45) Intrauterine medications intended for fetus 46) Glacial acetic acid 47) EPINEPHrine, subcutaneous or IM 48) Others: Please list

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