High-risk medication management protocol

Medication & Equipment

KEIT DAY HOSPITAL

High-risk medication management protocol

Official Manual of Clinical, Care and Organizational Protocols

1. Document Control Information

2. Scope of Application

Applicable to high-risk medications such as anticoagulants, vasopressors, opioids, anesthetics, concentrated electrolytes, insulin and other critical medications identified by the facility.

3. Responsibilities

• Physicians: clear, complete and appropriate prescribing of medications.
• Nurses and nurse anesthetists: preparation, labeling, independent double-checking and safe administration of medications.
• Pharmacy or Supply Manager: appropriate storage and segregation of high-risk medications.

4. Operating Procedure

• Identify high-risk medications and maintain an up-to-date list.
• Store these medications separately or ensure they are clearly identified.
• Apply an independent double-check process for preparation and administration whenever required.
• Always label syringes, infusions and infusion pumps clearly and legibly.
• Immediately report any medication error or near miss and initiate a root cause analysis.
• Monitor the patient appropriately during and after medication administration.

5. KEIT Operational Standards

• The anesthesia department applies rigorous labeling and verification procedures for infusions.
• Medication-related non-conformities are subject to dedicated audits.

6. Records and Documentation

• High-risk medication list.
• Medication event and near-miss register.
• Staff training records.

7. Review and Updates

Updates following the introduction of new medications, incidents or organizational revisions.

8. Related Attachments and Forms

• Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
• Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.

9. Final Approval