A Pinch - Clinical Excellence Commission PDF

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About the CEC

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Keep patients safe

A PINCH

(http://cec.health.nsw.gov.au/keeppatientssafe)

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COVID-19 Infection While the medicines identified as high-risk may vary between hospitals and clinical units depending on the types ofPrevention medicines and usedControl and patients treated, analysis of incident data and review of the published literature identified a group of medicines that should universally be considered as high-risk. These medicines include anti-infective agents, anti-psychotics, potassium, insulin, narcotics and sedative agents, Infection Prevention and chemotherapy and heparin and other anticoagulants. These medicines are represented by the acronym 'A PINCH'.Control The poster below can be used to assist hospitals in raising awareness of A PINCH medicines.

Falls prevention High-Risk Medicines A PINCH Poster (http://cec.health.nsw.gov.au/__data/assets/pdf_file/0007/296521/High-RiskDeteriorating patients Medicines_apinchposter.pdf)

(http://cec.health.nsw.gov.au/keeppatientssafe/medicationsafetyandquality)

To assist hospitals in monitoring risks associated with high-risk medicines, the tool below can also be used to monitor local implementation Sepsis and compliance with the NSW Health High-Risk Medicines Management Policy (PD2019_058 (https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2019_058)). Medication Safety and

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Quality High-Risk Medicines Management Implementation Checklist (http://cec.health.nsw.gov.au/__data/assets/pdf_file/0006/296520/HighRisk-Medicines-Management-Implementation-Checklist-Mar-2020.PDF)

Antimicrobial Stewardship (http://cec.health.nsw.gov.au/k patients-safe/medicationThe table below provides: safety-andExamples of high-risk medicines quality/antimicrobialLinks to information and recommendations for specific drugs covered by A PINCH. stewardship) Links to selected clinical indicators from the National Quality Use of Medicines in Australian Hospitals (QUM Indicators) to support Continuity of Medication hospitals in the monitoring of high-risk medicines use. Management (http://cec.health.nsw.gov.au/k High-Risk Medicine Groups Examples of medicines Link to Link to information QUM Indicators patients-safe/medicationA: Anti-infective Amphotericin safety-andNon-lipid and lipid formulations of injectable 2.3: Duration of empirical aminoglycoside amphotericin (http://www.npsa.nhs.uk/nrls/alerts- therapy (http://www.nswtag.org.au/qum-indicaAminoglycosides quality/continuity-ofand-directives/rapidrr/injectableamphotericin/) tors-set-2/) medication-management) (NPSA-UK)

'A PINCH' Table

P: Potassium and other electrolytes

Injections of potassium, magnesium, calcium, hypertonic sodium chloride

High-Risk Medicine Management Policy Directive Potassium (Intravenous) Standard (https://www1.health.nsw.gov.au/pds/Pages/doc. aspx?dn=PD2019_058) (NSW Health)

I: Insulin

All insulins

Safe Administration of Medication Pen Devices (http://cec.health.nsw.gov.au/__data/as-

6.1: Potassium ampoule storage outside

High-Risk Medicines (http://cec.health.nsw.gov.au/k cators-set-6/) patients-safe/medicationsafety-and-quality/highNil risk-medicines)

pharmacy (http://www.nswtag.org.au/qum-indi-

sets/pdf_file/0008/497231/Safe-administration-

Venous Thromboembolism (VTE) prevention (http://cec.health.nsw.gov.au/k High-Risk Medicine Management Policy Di4.1-Documentation of pain intensity rective (http://www.nswtag.org.au/qum-indicators-set-4/) patients-safe/medicationHydromorphone Standard 4.2-Pain management plan at discharge safety-and-quality/vte(https://www1.health.nsw.gov.au/pds/Pages/doc. (http://www.nswtag.org.au/qum-indicators-set-4/) prevention) aspx?dn=PD2019_058) (NSW Health) 5.7-Sedatives at discharge (http://www.nof-medication-pen-devices.pdf) (Clinical Excellence Commission)

N: Narcotics (opioids) and other sedatives

Hydromorphone, oxycodone, morphine fentanyl, alfentanil, remifentanil and analgesic patches, Benzodiazepines, for example, diazepam, midazolam. Thiopentone, propofol and other short term anaesthetics

Opioid Skin Patches are High Risk Medicines (http://www.nswtag.org.au/wp-content/uploads/2017/08/1.-Opioid-Skin-Patches-Advisory_Updated_November_2019.pdf) (NSW Therapeutic Advisory Group) Quick Steps through Opioid Management (https://www.aci.health.nsw.gov.au/chronicpain/health-professionals/quick_step-

swtag.org.au/qum-indicators-set-5/)

Barcode Scanning 6.3-Parenteral pethidine (http://www.nswtag.org.au/qum-indicators-set-6/)

(http://cec.health.nsw.gov.au/k patients-safe/medicationsafety-and-quality/barcodescanning)

s_through_opioid_management)

Medicine ingredient names (http://cec.health.nsw.gov.au/k (http://www.health.nsw.gov.au/sabs/Documents/ patients-safe/medication2006-sn-005.pdf) safety-and(NSW Health) quality/medicine3.6-Protocol based chemotherapy High-Risk Medicine Management Policy Diingredient-names) (http://www.nswtag.org.au/qum-indicators-set-3/) rective Vincristine Standard (Agency for Clinical Innovation) Safe Use of Fentanyl Skin Patches

C: Chemotherapeutic agents

Vincristine Methotrexate Etoposide Azathioprine

(https://www1.health.nsw.gov.au/pds/Pages/doc. aspx?dn=PD2019_058) (NSW Health)

Medication Safety Self Assessment (http://cec.health.nsw.gov.au/k patients-safe/medicationsafety-and-quality/mssa)

H: Heparin and anticoagulants

warfarin enoxaparin rivaroxaban dabigatran apixaban

High-Risk Medicine Management Policy Di-

1.3-Enoxaparin dosing (http://www.n-

National Standard

rective Anticoagulant Standard (http://www0.health.n-

swtag.org.au/qum-indicators-set-1/) Medication 1.4-Warfarin initiationChart (http://www.n-

sw.gov.au/policies/pd/2015/PD2015_029.html) (NSW Health)

swtag.org.au/qum-indicators-set-1/) (http://cec.health.nsw.gov.au/k 1.5-Warfarin dose review (http://www.n-

Intravenous Unfractionated Heparin Rec-

patients-safe/medication-

swtag.org.au/qum-indicators-set-1/)

safety-and-quality/Nationalommended Standard (http://cec.health.nsw.gov1.6-AF patients discharge on anticoagulant .au/keep-patients-safe/medication-safety-and- (http://www.nswtag.org.au/qum-indicators-set-1/) Standard-Medicationquality/high-risk-medicines/anticoagulants) (Clin5.4-Warfarin written information Chart) ical Excellence Commission) (http://www.nswtag.org.au/qum-indicators-set-5/) NOAC Guidelines (http://cec.health.nsw.gov.au/keep-patients-safe/medication-safetyand-quality/high-risk-medicines/anticoagulants) (Clinical Excellence Commission) Perioperative Management of Anticoagulant and Antiplatelet Agents (http://cec.health.nsw.gov.au/keep-patients-safe/medication-safetyand-quality/high-risk-medicines/anticoagulants) (Clinical Excellence Commission)

Other

High-risk medicines identified at Local High-Risk Medicine Management Policy Directive Paracetamol Standard Health District/ Facility/Unit level which do (https://www1.health.nsw.gov.au/pds/Pages/doc. not fit the above categories. aspx?dn=PD2019_058) (NSW Health) NOAC Guidelines (http://cec.health.nsw.gov.au/keep-patients-safe/medication-safetyand-quality/high-risk-medicines/anticoagulants) (Clinical Excellence Commission)

NSW Community Pharmacy Palliative Care (http://cec.health.nsw.gov.au/k patients-safe/medicationsafety-and-quality/nswcommunity-pharmacypalliative-care) Publications (http://cec.health.nsw.gov.au/k patients-safe/medicationsafety-andquality/publications)

Tall Man Lettering (http://cec.health.nsw.gov.au/k Transdermal patches: patients-safe/medicationsafety-and-quality/tall-manConfirmation from the prescriber should be sought if multiple patches are to be applied. The time of application, site of application and time of removal should be documented on the medication chart. lettering)

Examples of dose specific safety measures

Transdermal patches should not be exposed to extremes of temperature. Transdermal patches should not be cut. Transdermal patches containing opioids should be securely disposed of, for example, in sharps bin.

Modified release oral medicines, for example, slow release formulations:

User-Applied Labelling (http://cec.health.nsw.gov.au/k patients-safe/medicationsafety-and-quality/userapplied-labelling)

These formulations should not be dissolved, divided (unless scored), or crushed prior to administration. Pharmacy department should be contacted for advice on an alternative formulation, or dose preparation, if a patient has Links difficulty External swallowing. (http://cec.health.nsw.gov.au/k

Medicines inhaled using devices: Ensure the patient understands and is able to use the devices correctly. Ensure the device settings are correct for each medicine delivery Ensure use of the correct dose form and strength.

Parenteral fluids:

patients-safe/medicationsafety-and-quality/externallinks) Human Factors

Neonatal When available, high-risk medicines are purchased in a form closest to the dilution and strength in which theyMaternity are to be and administered, Safety Program so as to minimise opportunity for error in ward-based preparation. Pre-mixed infusion of fluids of high-risk medicines are to be used in preference to those locally prepared. injury prevention The need to vary from pre-mixed infusion strengths is clearly indicated and documented in the patient's healthPressure care record. Infusion pumps with intelligence-activated (smart) pumps are to be used, where available, to screen for dose, dilution and rate of Blood Watch administration. Intelligence checks are not to be bypassed without obtaining the clinical expertise of a senior clinician. End of Life Care Accessibility (http://cec.health.nsw.gov.au/accessibility) | NSW Government (http://www.nsw.gov.au) | Privacy (http://cec.health.nsw.gov.au/privacy-statement) | NSW Ministry of Health (http://www.health.nsw.gov.au) | Paediatric program Disclaimer (http://cec.health.nsw.gov.au/disclaimer) Review incidents

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