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Developing national level high alert medication lists for acute care setting in Korea

국내 급성기 의료기관 고위험 의약품 목록 도출

  • Han, Ji Min (College of Pharmacy, College of Pharmacy, Chungbuk National University) ;
  • Heo, Kyu-Nam (College of Pharmacy, Seoul National University) ;
  • Lee, Ah Young (College of Pharmacy, Seoul National University) ;
  • Min, Sang il (Department of Surgery, Seoul National University Hospital) ;
  • Kim, Hyun Jee (Drug Safety Monitoring Center, Seoul National University Hospital) ;
  • Baek, Jin-Hee (Department of Pharmacy, Seoul National University Hospital) ;
  • Rho, Juhyun (Department of Pharmacy, Seoul National University Bundang Hospital) ;
  • Kim, Sue In (Department of Pharmacy, Chungbuk National University Hospital) ;
  • Kim, Ji yeon (Department of Pharmacy, Chungnam National University Hospital) ;
  • Lee, Haewon (Quality and Patient Safety Center, Seoul National University Hospital) ;
  • Cho, Eunju (Quality and Patient Safety Center, Seoul National University Hospital) ;
  • Ah, Young-Mi (College of Pharmacy, Yeungnam University) ;
  • Lee, Ju-Yeun (College of Pharmacy, Seoul National University)
  • 한지민 (충북대학교 약학대학) ;
  • 허규남 (서울대학교 약학대학) ;
  • 이아영 (서울대학교 약학대학) ;
  • 민상일 (서울대학교병원 외과) ;
  • 김현지 (서울대학교병원 지역의약품안전센터) ;
  • 백진희 (서울대학교병원 약제부) ;
  • 노주현 (분당서울대학교병원 약제부) ;
  • 김수인 (충남대학교병원 약제부) ;
  • 김지연 (충북대학교병원 약제부) ;
  • 이해원 (서울대학교병원 QPS 센터) ;
  • 조은주 (서울대학교병원 QPS 센터) ;
  • 아영미 (영남대학교 약학대학) ;
  • 이주연 (서울대학교 약학대학)
  • Received : 2022.05.31
  • Accepted : 2022.06.19
  • Published : 2022.06.30

Abstract

Background: High-alert medications (HAMs) are medications that bear a heightened risk of causing significant patient harm if used in error. To facilitate safe use of HAMs, identifying specific HAM lists for clinical setting is necessary. We aimed to develop the national level HAM list for acute care setting. Methods: We used three-step process. First, we compiled the pre-existing lists referring HAMs. Second, we analyzed medication related incidents reported from national patient safety incident report data and adverse events indicating medication errors from the Korea Adverse Event Reporting System (KAERS). We also surveyed the assistant staffs to support patient safety tasks and pharmacist in charge of medication safety in acute care hospital. From findings from analysis and survey results we created additional candidate list of HAMs. Third, we derived the final list for HAMs in acute care settings through expert panel surveys. Results: From pre-existing HAM list, preliminary list consisting of 42 medication class/ingredients was derived. Eight assistant staff to support patient safety tasks and 39 pharmacists in charge of medication safety responded to the survey. Additional 44 medication were listed from national patient safety incident report data, KAERS data and common medications involved in prescribing errors and dispensing errors from survey data. A list of mandatory and optional HAMs consisting of 10 and 6 medication classes, respectively, was developed by consensus of the expert group. Conclusion: We developed national level HAM list for Korean acute care setting from pre-existing lists, analyzing medication error data, survey and expert panel consensus.

Keywords

Acknowledgement

본 연구는 보건복지부의 재원으로 한국보건산업진흥원의 보건의료기술연구 개발사업 지원에 의하여 이루어진 것임(HI21C1389).

References

  1. Institute for Safe Medication Practice, High-Alert Medications in Acute Care Settings. Available from https://www.ismp.org/recommendations/high-alert-medications-acute-list. Accessed August 20, 2021.
  2. Winterstein AG, Hatton RC, Gonzalez-Rothi R, Johns TE, Segal R. Identifying clinically significant preventable adverse drug events through a hospital's database of adverse drug reaction reports. Am J Health Syst Pharm 2002;59(18):1742-9. https://doi.org/10.1093/ajhp/59.18.1742
  3. Institute for Healthcare Improvement. 5 Million Lives Campaign an initiative of the institute for Healthcare Improvement. Available from http://www.ihi.org/about/documents/5millionlivescampaigncasestatement.pdf. Accessed August 20, 2021.
  4. World Health Organization. Medication safety in high-risk situations (No. WHO/UHC/SDS/2019.10). Available from https://apps.who.int/iris/bitstream/handle/10665/325131/WHO-UHCSDS-2019.10-eng.pdf. Accessed August 20, 2021.
  5. Ministry of Health & Welfare. Korea Institute for Healthcare Accreditation. The 4th acute care hospitals accreditation criteria. Sejong, Seoul: Ministry of Health & Welfare, Korea Institute for Healthcare Accreditation. Available from https://www.koiha.or.kr/web/kr/library/establish_board.do. Accessed August 20, 2021.
  6. Saedder EA, Brock B, Nielsen LP, Bonnerup DK, Lisby M. Identifying high-risk medication: a systematic literature review. Eur J Clin Pharmacol 2014;70(6):637-645. https://doi.org/10.1007/s00228-014-1668-z
  7. Tyynismaa L, Honkala A, Airaksinen M, Shermock K, Lehtonen L. Identifying high-alert medications in a university hospital by applying data from the medication error reporting system. J Patient Saf 2021;17(6):417-24. https://doi.org/10.1097/PTS.0000000000000388
  8. Otero MJ, Moreno-Gomez AM, Santos-Ramos B, Agra Y. Developing a list of high-alert medications for patients with chronic diseases. Eur J Intern Med 2014;25(10):900-8. https://doi.org/10.1016/j.ejim.2014.10.021
  9. Washburn NC, Dossett HA, Fritschle AC, Degenkolb KE, Macik MR, Walroth TA. High-alert medication stratification tool-revised: An exploratory study of an objective, standardized medication safety tool. J Patient Saf 2021;17(7):e672-83. https://doi.org/10.1097/PTS.0000000000000445