医院降低高警讯药物对病患伤害的建议策略，发表于九月照护安全与品质联合委员会期刊（Joint Commission Journal on Quality and Healthcare Safety）的一篇报告中，本期刊中还有一篇案例研究，描述Fairview健康服务中心降低严重镇静剂过度镇静比率的努力。
健康照护改善中心的Frank Federico博士指出，健康照护改善中心(IHI)的12介入中心，在其5百万救命活动(此活动设定的目标是在2006年12月到2008年12月减少5百万件意外)中提出建议：预防高警讯药物。
从抗凝血药、镇静剂、止痛药和胰岛素开始，药物是住院病患健康照护最常使用的治疗方式，也是最常发生不良反应的；根据药物研究中心(IOM)的报告－预防药物疏失，在美国每年发生150万件可预防的不良药物事件(ADEs)，而住院病患每年发生40万 件不良药物事件而导致35亿美金的额外损失。
改善抗凝血剂的特殊安全建议如下：
* 制定抗凝血剂药物安全单张与规范，要求病患出院到照护机构或返家时遵守。
* 对住院和门诊病患提供抗凝血剂量服务或者诊间谘询。
* 检查数据必须提供给对此数据能有所因应的照护者。
* 允许药师依照给药规范并参考检查数据调整抗凝血剂剂量。
* warfarin的开始剂量须限制在2.5或5mg，依照病患的年纪和/或共病症而定。
* 必须对药物处方进行药物交互作用确认。
改善肝素(heparin)的特殊安全建议如下：
* 建立和遵守标准给药剂量规范。
* 如果发生肝素过量而过度抗凝血时，须有停用肝素或逆转治疗的规范。
* 将可用浓度降到最低，以简化和降低潜在风险。
改善warfarin的特殊安全建议如下：
* 开始和维持warfarin治疗须有标准规范，这些包括维他命k剂量规范。
* 需发展有实证基础的手术间续用或停用warfarin的规范。
* 检查数据须在两个小时内提供给照护单位，或者直接在病床边监测。
* 国际标准化比率(INR)结果和剂量改变的关系必须纪录在推移图(The Run Chart)或者管制图(control chart)。
* 病患和家属必须参加自我管理。
改善止痛药/鸦片类的特殊安全建议如下：
* 开始和维持疼痛管理的规范需标准化。
* 需要适当监测以侦测止痛药和鸦片类药物的副作用。
* 须有解毒剂和使用规范，以便在无医嘱下仍可进行。
* 如果照护医师没有疼痛控制经验，需谘询疼痛专家；依照临床经验，这些专家包括护士、药师、外科医师或者其他有经验者。
* 需尽可能采取非药理介入处置疼痛和焦虑。
* 止痛帮浦需设定程式并由药局或护士进行二度确认。
* 病患自控止痛药以及硬脑(脊)膜外止痛药必须在护理站内二度确认。
* 如果可以，尽量减少或不用多种止痛药物。
改善胰岛素的特殊安全建议如下：
* 开始使用任何静脉胰岛素之前，药物种类、浓度、剂量、帮浦设定、给药途径、病患本身因素都必须再次确认。
* 事先规定好的糖尿病与胰岛素输注表单。
* 外观相似和药名相似的药物必须以不同标示分开，给药时间也应区隔，储放距离也须分开。
* 所有的输液必须在药局内准备，并且以单一浓度提供。
* 病患应可以自我管理其胰岛素。
* 需调节用餐和使用胰岛素的时间。
改善镇静剂的特殊安全建议如下：
* 储存和处方的口服中效镇静剂应该只有浓度。
* 使用事先印好的医嘱形式处方麻醉型止痛药和镇静剂。
* 使用chloral hydrate进行术前镇静的所有小孩，必须在手术前中后加以监控。
* 在病患镇静进行手术的过程中，一如其他服用镇静剂的状况，需备妥适合病患年纪与体型的复苏设备和相关药剂。
Federico医师指出，5百万救命活动聚焦在高警讯药物，是降低药物引起伤害之整体策略的一部分，此活动的目标是降低50%的高警讯药物相关伤害，组织一些安全策略，如重新设计给药途径、让病患参与、建立安全文化、减少责怪与加强沟通、对高风险药物的使用加以标准化和简单化之后，ADEs 可以显著减少。
来自Fairview健康服务中心的Steven Meisel及其同事所进行的案例研究中，描述了麻醉型止痛药物过度镇静案例的减少情况，他们是透过整合7家医院、30家一线照护诊所、31间零售药局、居家照护和安宁机构和其他许多计划。
作者指出，1999年12月时，Fairview Southdale医院发生令人震惊的事件，健康病患因为麻醉型止痛药过量而呼吸衰竭致死案例，此案例特别麻烦，因为给药剂量属常规且合乎惯例，没有明显的药物疏失，且当时的病患监测数据都在安全标准内；为了确定此案例是单一个案或是一种类型的一部分，因而回顾了两个月以内的所有使用naloxone案例。
结果发现有11件严重过度镇静案例，刺激医界评估及校正麻醉型止痛剂过度镇静的相关因子。
Fairview Southdale医院在2000年4月组织了一个包含护士、药师、麻醉技师、家庭医师、呼吸治疗师、麻醉医师以及品管人员的委员会，希望降低严重麻醉型止痛剂过度镇静达75%。
严重(第3和第4类)事件每月追踪，每年计算比率，在追踪到第12个月时，该团队检测和执行34项改变，包括病患评估和监测、个人化麻醉剂治疗、以及跨科与跨部门沟通。
在2001年中时，达到降低严重不良反应达75%的目标。
作者结论表示，Fairview 疼痛委员会持续进行可以改善的机会，严重度分类系统转到“国际药物错误报告及预防委员会(NCC MERP)”系统，有助于我们确认额外的改善机会；从手术步骤如内视镜手术、二氧化碳浓度监测仪(Capnography)使用规范开始发展，新的病患控制麻醉药物和硬脑(脊)膜外帮浦需内建安全的特征、医嘱设定须不断地再确认。
Hospitals Can Reduce Patient Harm Related to High-Alert Medications By Laurie Barclay,MD
Medscape Medical News
Recommended strategies for hospitals to reduce patient harm related to high-alert medications are presented in a report in the September issue of the Joint Commission Journal on Quality and Healthcare Safety.A case study in the same issue describes the effort made by Fairview Health Services to reduce the rate of serious narcotic oversedation."One of the12interventions that the Institute for Healthcare Improvement(IHI)recommends for its5Million Lives Campaign — which has set a target of reducing five million incidents of harm from December2006to December2008— is 'Prevent Harm from High-Alert Medications...starting with a focus on anticoagulants,sedatives,narcotics,and insulin,'" writes Frank Federico,RPh,from the Institute for Healthcare Improvement in Cambridge,Massachusetts."Medications are the most common intervention in health care and are also most commonly associated with adverse events in hospitalized patients.According to the Institute of Medicine(IOM)report,Preventing Medication Errors,1.5million preventable adverse drug events(ADEs)occur each year in the United States,and400,000adverse drug events that occur each year in hospitalized patients result in $3.5billion in additional costs."Specific recommendations to improve safety with the use of anticoagulants are as follows:． Formatted anticoagulation flow sheets and orders should follow the patient through transfers from hospital,to skilled care facility,to home.． An anticoagulant dosing service or "clinic" is needed in both inpatient and outpatient settings.． Laboratory results should be reported to a provider who can act on the findings.． Pharmacists should be permitted to change doses of antithrombotic agents based on laboratory values by following protocols approved by medical staff.． The starting dose of warfarin should be limited to2.5or5mg,depending on patient age and/or comorbidities.． Medication orders should be checked for drug interactions.Specific recommendations to improve safety with the use of heparin are as follows:． Standardized protocols and dosing should be established and implemented.． Guidelines to hold heparin and give reversal treatment of heparin overanticoagulation should be developed.． Minimizing the number of available concentrations allows simplification and reduces the potential for errors.Specific recommendations to improve safety with the use of warfarin are as follows:． Standardized protocols should be used when starting and maintaining of warfarin therapy.These should include vitamin K dosing guidelines.． An evidence-based protocol should be developed to discontinue and restart warfarin perioperatively.． Laboratory results should be made available on the unit within2hours or should be monitored at the bedside.． International normalized ratio results vs dose changes should be plotted on the run chart or control chart.． Patients and families should participate in self-management.Specific recommendations to improve safety with the use of narcotics/opiates are as follows:． Protocols to begin and maintain pain management should be standardized.． Appropriate monitoring is needed to detect adverse effects of narcotics and opiates.． Protocols and reversal agents should be available that can be given without needing additional physician orders.． When the managing physicians are not experienced in pain control,a pain specialist should be consulted.Depending on the clinical setting,these may include specially trained nurses,pharmacists,physicians,or others.． Nonpharmacologic intervention for pain and anxiety should be maximized.． All pumps should be programmed and independently double-checked by pharmacy or nursing staff.． Patient-controlled analgesia and epidural narcotics should be independently double-checked on the unit.． Whenever possible,multiple drug strengths should be minimized or eliminated.Specific recommendations to improve safety with the use of insulin are as follows:． Before administering any intravenous insulin,the drug,concentration,dose,pump settings,route of administration,and patient identity should be independently double-checked.． Pretyped forms are recommended for diabetic and insulin infusion orders.． Look-alike and sound-alike drugs should be separated by labeling,time,and distance.． All infusions should be prepared in the pharmacy and standardized to a single concentration of intravenous infusion insulin.． Patients who are able to should manage their own insulin.． Meal and insulin times should be coordinated.Specific recommendations to improve safety with the use of sedatives are as follows:． Only1concentration of oral agents for moderate sedation should be stocked and prescribed.． Preprinted order forms should be used to order narcotics and sedatives.． All children who have received chloral hydrate for preoperative sedation should be monitored before,during,and after the procedure.． During procedures performed while the patient is sedated,as well as in other situations where sedatives are administered,age-and size-appropriate resuscitation equipment and reversal agents should be available."The5Million Lives Campaign's focus on high-alert medications is part of an overall strategy to reduce medically induced harm," Dr.Federico writes."The campaign's goal is to achieve a50%reduction in harm related to high-alert medications.ADEs can be reduced significantly by implementing recognized safety measures,such as standardizing and simplifying core medication processes in known high-risk areas,redesigning delivery systems using proven human factors principles,partnering with patients,and creating safety cultures that minimize blame and maximize communication."The accompanying case study,by Steven Meisel,PharmD,from Fairview Health Services in Minneapolis,Minnesota,and colleagues,describes how narcotic oversedation was reduced across an integrated health system composed of7hospitals,30primary care clinics,31retail pharmacies,a home care and hospice agency,and various other programs."In December1999,Fairview Southdale Hospital was devastated by the death of an otherwise healthy patient from an apparent narcotic-associated respiratory depression," the authors write."This case was particularly troublesome because the doses administered were usual and customary,there were no identified medication errors,and patient monitoring was conducted within all standards at that time.To determine if this case was an isolated event or was part of a pattern,all naloxone administration during a two-month period was retrospectively reviewed."Eleven cases of serious oversedation were identified,which provided the impetus to evaluate and correct the factors associated with narcotic oversedation.Fairview Southdale Hospital commissioned a team of nurses,pharmacists,anesthetists,a house physician,respiratory therapists,anesthesiologists,and quality resource staff in April2000to decrease serious narcotic oversedation by75%.Serious(class3and4)events were tracked monthly,and rates were annualized.During the following12months,the team tested and implemented34changes involving patient assessment and monitoring,individualizing analgesic treatment,and interdisciplinary and interdepartmental communication.The goal of a75%reduction in serious adverse drug events was reached by mid2001."The Fairview Pain Committee continues to identify opportunities for improvement," the authors conclude."The severity coding system has been changed to the National Coordinating Council for Medication Error Reporting and Prevention(NCC MERP)system,which should help us identify additional opportunities for improvement.Work is beginning on oversedation in procedural areas such as endoscopy,guidelines for the use of capnography are being developed,new patient-controlled analgesia and epidural pumps are being purchased that have greater inherent safety features,and order sets are undergoing continual refinement."Jt Comm J Qual Patient Saf.2007;33:537-542,543-548.
