Korean J Clin Pharm.  2022 Jun;32(2):116-124. 10.24304/kjcp.2022.32.2.116.

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

• Han JM
• Heo KN
• Lee AY
• Min Si
• Kim HJ
• Baek JH
• Rho J
• Kim SI
• Kim Jy
• Lee H
• Cho E
• Ah YM
• Lee JY

• KMID: 2531010
• DOI: http://doi.org/10.24304/kjcp.2022.32.2.116

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.

Keyword

High-alert medication; medication safety; acute care setting; national patient safety incident report