High alert medications off the radar: A systematic review

Area of Science:

• Pharmacovigilance
• Patient Safety
• Critical Care Medicine

Background:

• Medication errors pose a significant threat to patient safety, particularly in critical care settings.
• High Alert Medications (HAM) are recognized for their potential to cause significant harm when administered incorrectly.
• Existing HAM lists may not encompass all drugs with a high risk of causing damage.

Purpose of the Study:

• To identify drugs not currently classified as High Alert Medications (HAM) that present an increased risk of severe harm to critically ill patients due to administration errors.
• To evaluate the potential for medication administration failures to lead to significant patient damage.

Main Methods:

• A systematic literature review was conducted across multiple databases (PubMed, Lilacs, Scopus, Web of Science) and gray literature.
• The review included studies without time restrictions, analyzing medication errors and their impact on critically ill patients.
• Seven articles were included after an initial screening of 1477 studies and full-text evaluation of 50 manuscripts.

Main Results:

• Medication errors most frequently occurred during the administration and prescription phases.
• All included studies reported incidents where drugs led to patient harm.
• Risperidone and piperacillin-tazobactam, along with the Infectious Agent class, were identified as drugs not on official HAM lists that carry an increased risk of harm due to errors.

Conclusions:

• Drugs not currently listed as HAM can indeed pose substantial risks of harm to critically ill patients when medication errors occur.
• These identified drugs, including risperidone and piperacillin-tazobactam, should be considered for inclusion in future official lists of High Alert Medications.
• Enhancing HAM lists can contribute to improved medication safety protocols and reduced patient harm in critical care environments.