Focus on patient safety -  "High-alert medications. Underestimating the risk is risky."

Context 

The yearly report on care-related serious adverse events showed, from 2018, that adverse events related to health products were the third most common cause behind the serious adverse events reported.  

Among the errors received by the HAS from March 2017 to 31 December 2019, 75% were related to so-called “high-alert” medications. Defined by the order of 6 April 20111 it most often concerns “ medications with narrow therapeutic index” which carry an increased risk of causing significant harm to the patient. Whether errors are more common or not with these medications, they clearly have more catastrophic outcomes for patients.  

Objectives 

By sharing this feedback from professionals faced with these care-related serious adverse events, this information sheet can be used to alert them as to the recurrence of serious adverse events caused by misuse of high-alert medications at all stages of medication management, and to raise awareness as to good practice guidelines which could have been used to avoid them. 

So it doesn’t happen again  

This safety information sheet highlights in a general manner how these errors point most often to non-observance of good practices, insufficient supervision and/or training, a deficient work environment, leading to serious consequences for patients every time.  

Observance of good prescription, dispensing, administration and follow-up practices are safety barriers at each stage of medication management, for each of the main categories of high-alert medications. Specific information sheets for each, summarising these good practice guidelines, will be put forward in the coming months. The first information sheet will cover potassium chloride. 

This safety information sheet was devised in collaboration with the medication, medical device and therapeutic innovation observatory (Observatoires du Médicament, des Dispositifs médicaux et de l'Innovation Thérapeutique - OMéDITS), which makes it possible to pool tools available to professionals, while offering them the opportunity to self-asses, to assess their organisation or to train, at regional level, in liaison with the OMéDITS (E-learning, training on good prescription, dispensing, and administration practices, continuous professionnal development…).