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LittleMeds Safety

Version 1.0 | Review date: ____________________

Pediatric High-Alert Medication Review

Professional notice: This review must be used with the organization's approved high-alert medication list, formulary, policies, standard concentrations, smart-pump library, and monitoring requirements. It does not establish medication doses or treatment standards.

Review Information

Facility or organization
Department or unit
Reviewer
Review date
Medication or medication class
Population or care area
Relevant policy
Policy version or revision date
Standard concentration reference
Smart-pump library version
Previous review date
Notes

Medication Class Selection

Select the medication or class being reviewed. Print the matching appendix module pages as needed.

Primary Blank Review Form

Complete the standard assessment domains below. Medication-specific modules are provided in the appendix so users may print only the pages needed for the selected medication class.

Governance and Ownership

Criterion text Compliant Deficient N/A
Medication or class is included on the institution-approved high-alert medication list Compliant Deficient N/A
An accountable committee or service owns the medication-safety process Compliant Deficient N/A
Policies define prescribing, preparation, dispensing, administration, and monitoring expectations Compliant Deficient N/A
Policies identify approved clinical locations and authorized users Compliant Deficient N/A
Safeguards are reviewed on a defined schedule Compliant Deficient N/A
Medication-use data and safety events are reviewed by leadership Compliant Deficient N/A
Changes follow a documented approval and communication process Compliant Deficient N/A
Notes:

Prescribing

Criterion text Compliant Deficient N/A
Orders use kilograms as the dosing weight when weight-based dosing applies Compliant Deficient N/A
The weight used for dosing is visible and current Compliant Deficient N/A
Standardized order sets are available when appropriate Compliant Deficient N/A
Dose units are clearly defined Compliant Deficient N/A
Maximum doses or dose limits are defined when appropriate Compliant Deficient N/A
Indication is included when clinically useful Compliant Deficient N/A
Required baseline laboratory or clinical information is available Compliant Deficient N/A
Duplicate therapy and contraindication checks are supported Compliant Deficient N/A
Verbal or handwritten orders are restricted according to policy Compliant Deficient N/A
Decimal notation avoids trailing zeros and uses leading zeros Compliant Deficient N/A
Free-text ordering is minimized Compliant Deficient N/A
Titration parameters are clearly defined when applicable Compliant Deficient N/A
Notes:

Pharmacist Verification

Criterion text Compliant Deficient N/A
Pharmacist verification is required before administration except for defined emergencies Compliant Deficient N/A
Patient weight and dosing weight are reviewed when applicable Compliant Deficient N/A
Dose, route, frequency, concentration, and indication are verified Compliant Deficient N/A
Maximum dose limits are evaluated Compliant Deficient N/A
Relevant laboratory values and organ function are reviewed Compliant Deficient N/A
Allergies and clinically significant interactions are reviewed Compliant Deficient N/A
Standard concentration compliance is verified Compliant Deficient N/A
Unusual doses or concentrations require documented clarification Compliant Deficient N/A
Escalation pathways are defined for unresolved concerns Compliant Deficient N/A
Emergency override use is reviewed after the event Compliant Deficient N/A
Notes:

Preparation and Compounding

Criterion text Compliant Deficient N/A
Pharmacy preparation is used whenever feasible Compliant Deficient N/A
Standard concentrations are defined Compliant Deficient N/A
Concentration options are limited Compliant Deficient N/A
Preparation instructions are standardized Compliant Deficient N/A
Calculations are independently verified when required by policy Compliant Deficient N/A
Final product labels clearly display drug name, dose, concentration, route, and expiration Compliant Deficient N/A
Pediatric syringe and container sizes are appropriate for the volume Compliant Deficient N/A
Small-volume measurements are performed with suitable devices Compliant Deficient N/A
Batch preparation and premixed products are used when appropriate Compliant Deficient N/A
Sterility and beyond-use requirements are clearly defined Compliant Deficient N/A
Manipulation at the bedside is minimized Compliant Deficient N/A
Look-alike products are differentiated during preparation Compliant Deficient N/A
Notes:

Dispensing and Storage

Criterion text Compliant Deficient N/A
Medication is stored only in approved locations Compliant Deficient N/A
Access is restricted where appropriate Compliant Deficient N/A
Different concentrations are physically separated Compliant Deficient N/A
Look-alike and sound-alike risks are addressed Compliant Deficient N/A
Neuromuscular blocking agents use prominent warning labels where applicable Compliant Deficient N/A
Storage labels clearly identify the medication as high alert Compliant Deficient N/A
Automated dispensing cabinet configuration limits selection errors Compliant Deficient N/A
Override access is restricted and reviewed Compliant Deficient N/A
Barcode scanning is used when available Compliant Deficient N/A
Refrigerated or protected storage requirements are maintained Compliant Deficient N/A
Expiration and inventory checks are assigned Compliant Deficient N/A
Pediatric-specific concentrations are distinguishable from adult concentrations Compliant Deficient N/A
Notes:

Administration

Criterion text Compliant Deficient N/A
Patient identity is confirmed using approved identifiers Compliant Deficient N/A
Medication, dose, route, time, concentration, and rate are verified Compliant Deficient N/A
Independent double checks are clearly defined when required Compliant Deficient N/A
The independent check occurs without prompting from the first clinician Compliant Deficient N/A
Barcode medication administration is used when available Compliant Deficient N/A
Smart-pump drug library use is required when applicable Compliant Deficient N/A
Line tracing is completed before administration Compliant Deficient N/A
Route-specific connections reduce wrong-route risk Compliant Deficient N/A
Bolus and infusion instructions are clearly distinguished Compliant Deficient N/A
Administration labels remain visible Compliant Deficient N/A
Titration and dose-change documentation is standardized Compliant Deficient N/A
Interruptions during preparation and administration are minimized Compliant Deficient N/A
Handoff communication includes active high-alert medications Compliant Deficient N/A
Notes:

Monitoring and Rescue Readiness

Criterion text Compliant Deficient N/A
Required baseline monitoring is defined Compliant Deficient N/A
Ongoing clinical and laboratory monitoring is defined Compliant Deficient N/A
Monitoring frequency reflects pediatric risk and medication characteristics Compliant Deficient N/A
Hold parameters and escalation criteria are available Compliant Deficient N/A
Adverse-effect recognition guidance is accessible Compliant Deficient N/A
Reversal agents or rescue medications are accessible when appropriate Compliant Deficient N/A
Rescue equipment is immediately available when required Compliant Deficient N/A
Post-administration reassessment is documented Compliant Deficient N/A
Monitoring responsibilities are clearly assigned Compliant Deficient N/A
Transitions between departments include monitoring requirements Compliant Deficient N/A
Discharge education includes relevant safety and monitoring instructions when applicable Compliant Deficient N/A
Notes:

Technology and Decision Support

Criterion text Compliant Deficient N/A
Pediatric dosing decision support is available Compliant Deficient N/A
Dose-range checking is configured appropriately Compliant Deficient N/A
Alerts use appropriate minimum and maximum dose logic Compliant Deficient N/A
Duplicate or low-value alerts are minimized Compliant Deficient N/A
Smart-pump entries match approved concentrations Compliant Deficient N/A
Dosing units are consistent across prescribing, pharmacy, and pump systems Compliant Deficient N/A
Hard and soft limits are reviewed on a defined schedule Compliant Deficient N/A
Alert overrides are monitored Compliant Deficient N/A
Barcode databases match stocked products Compliant Deficient N/A
System changes are tested before release Compliant Deficient N/A
Downtime procedures maintain high-alert medication safeguards Compliant Deficient N/A
Notes:

Education and Competency

Criterion text Compliant Deficient N/A
Staff receive medication-specific education before use Compliant Deficient N/A
Competency is assessed when required Compliant Deficient N/A
Education addresses pediatric dosing risks Compliant Deficient N/A
Education includes device and pump use when applicable Compliant Deficient N/A
Staff know how to access policies and references Compliant Deficient N/A
New concentrations or workflows require education before implementation Compliant Deficient N/A
Temporary and float staff receive appropriate guidance Compliant Deficient N/A
Competency gaps trigger remediation Compliant Deficient N/A
High-alert medication practices are included in orientation Compliant Deficient N/A
Emergency-use processes are included in drills or simulations when appropriate Compliant Deficient N/A
Notes:

Event Learning and Continuous Improvement

Criterion text Compliant Deficient N/A
Errors and near misses involving the medication are reviewed Compliant Deficient N/A
Event review focuses on system factors rather than individual blame Compliant Deficient N/A
Trends are evaluated across prescribing, preparation, administration, and monitoring Compliant Deficient N/A
Smart-pump and alert-override data are reviewed when available Compliant Deficient N/A
Corrective actions use strong system interventions when feasible Compliant Deficient N/A
Action plans identify owners and completion dates outside this assessment tool Compliant Deficient N/A
Effectiveness of corrective actions is measured Compliant Deficient N/A
Lessons are communicated to relevant teams Compliant Deficient N/A
Policy and technology changes are tracked Compliant Deficient N/A
Safeguards are reassessed after major events or workflow changes Compliant Deficient N/A
Notes:

Printable Review Summary

Total applicable criteria
Compliant
Deficient
Not applicable
Readiness percentage
Overall classification
Key findings
Recommended system actions
Reviewer signature and date
Leadership reviewer signature and date

Scoring Formula

Readiness percentage = Compliant ÷ (Compliant + Deficient) × 100

Suggested Classifications

  • 95-100%: Safeguards well established
  • 85-94%: Improvement opportunities identified
  • Below 85%: Priority system review recommended

These are suggested quality-improvement indicators and may be modified by institutional policy.

Appendix: Medication-Specific Modules

Print only the module pages needed for the selected medication class. These appendix criteria are not printed in the primary blank form by default.

Anticoagulants

Criterion text Compliant Deficient N/A
Pediatric dosing protocols are standardized Compliant Deficient N/A
Indication-specific dosing guidance is available Compliant Deficient N/A
Baseline and ongoing laboratory monitoring requirements are defined Compliant Deficient N/A
Renal and hepatic function considerations are addressed Compliant Deficient N/A
Reversal strategies are available Compliant Deficient N/A
Transitions between anticoagulants are standardized Compliant Deficient N/A
Peri-procedural management guidance is available Compliant Deficient N/A
Infusion concentrations and pump limits are standardized when applicable Compliant Deficient N/A
Bleeding escalation pathways are defined Compliant Deficient N/A
Caregiver education is standardized when applicable Compliant Deficient N/A
Notes:

Insulin

Criterion text Compliant Deficient N/A
Insulin concentration is prominently displayed Compliant Deficient N/A
U-100 and other concentrations are clearly differentiated Compliant Deficient N/A
"Units" is written in full where required by policy Compliant Deficient N/A
Insulin is measured with an appropriate insulin device Compliant Deficient N/A
Dose timing is coordinated with nutrition Compliant Deficient N/A
Blood glucose monitoring requirements are defined Compliant Deficient N/A
Hypoglycemia rescue protocols are immediately available Compliant Deficient N/A
Continuous infusion concentrations are standardized Compliant Deficient N/A
Transitions between intravenous and subcutaneous insulin are standardized Compliant Deficient N/A
Independent verification is used according to policy Compliant Deficient N/A
Notes:

Opioids

Criterion text Compliant Deficient N/A
Opioid-naive status and prior exposure are considered Compliant Deficient N/A
Dose limits are defined Compliant Deficient N/A
Equianalgesic conversion safeguards are available Compliant Deficient N/A
Sedation and respiratory monitoring requirements are defined Compliant Deficient N/A
Naloxone is immediately accessible Compliant Deficient N/A
Patient-controlled analgesia settings are standardized Compliant Deficient N/A
Basal infusion restrictions are defined Compliant Deficient N/A
Concomitant sedating medications are reviewed Compliant Deficient N/A
Concentrated opioid products are restricted Compliant Deficient N/A
Discharge quantities and caregiver education are standardized Compliant Deficient N/A
Notes:

Sedatives

Criterion text Compliant Deficient N/A
Sedation depth and intended level are defined Compliant Deficient N/A
Credentialing requirements are established Compliant Deficient N/A
Pre-sedation assessment is standardized Compliant Deficient N/A
Continuous monitoring requirements are defined Compliant Deficient N/A
Airway and resuscitation equipment are available Compliant Deficient N/A
Reversal agents are accessible when applicable Compliant Deficient N/A
Recovery and discharge criteria are standardized Compliant Deficient N/A
Sedative concentrations are limited Compliant Deficient N/A
Bolus and infusion limits are defined Compliant Deficient N/A
Concurrent sedating medications are reviewed Compliant Deficient N/A
Notes:

Neuromuscular Blocking Agents

Criterion text Compliant Deficient N/A
Storage is restricted to approved locations Compliant Deficient N/A
Auxiliary warning labels indicate respiratory paralysis risk Compliant Deficient N/A
Products are separated from routine medications Compliant Deficient N/A
Orders require a clear indication Compliant Deficient N/A
Mechanical ventilation and sedation are confirmed Compliant Deficient N/A
Independent verification is required according to policy Compliant Deficient N/A
Emergency access and override processes are controlled Compliant Deficient N/A
Continuous sedation and analgesia safeguards are defined Compliant Deficient N/A
Monitoring requirements are standardized Compliant Deficient N/A
Stocking outside critical-care areas is reviewed and justified Compliant Deficient N/A
Notes:

Vasoactive Medications

Criterion text Compliant Deficient N/A
Standard concentrations are used Compliant Deficient N/A
Smart-pump limits are configured Compliant Deficient N/A
Titration parameters are clearly ordered Compliant Deficient N/A
Required vascular access is defined Compliant Deficient N/A
Extravasation management guidance is available Compliant Deficient N/A
Continuous hemodynamic monitoring is defined Compliant Deficient N/A
Dose units are standardized Compliant Deficient N/A
Bolus administration restrictions are defined Compliant Deficient N/A
Handoff communication includes current dose and recent changes Compliant Deficient N/A
Rescue and escalation processes are available Compliant Deficient N/A
Notes:

Concentrated Electrolytes

Criterion text Compliant Deficient N/A
Floor stock is restricted Compliant Deficient N/A
Products are segregated and prominently labeled Compliant Deficient N/A
Pharmacy preparation is used whenever feasible Compliant Deficient N/A
Standard concentrations are defined Compliant Deficient N/A
Maximum rates and concentrations are available Compliant Deficient N/A
Required laboratory monitoring is defined Compliant Deficient N/A
Smart-pump limits are configured Compliant Deficient N/A
Bolus administration restrictions are explicit Compliant Deficient N/A
Emergency access processes are controlled Compliant Deficient N/A
Look-alike packaging risks are addressed Compliant Deficient N/A
Notes:

Chemotherapy

Criterion text Compliant Deficient N/A
Protocol and cycle verification are standardized Compliant Deficient N/A
Diagnosis, regimen, body-size calculation, and cumulative dose are verified Compliant Deficient N/A
Independent verification requirements are defined Compliant Deficient N/A
Intrathecal medications are segregated from intravenous chemotherapy Compliant Deficient N/A
Route-specific preparation and delivery controls are used Compliant Deficient N/A
Laboratory and organ-function parameters are reviewed Compliant Deficient N/A
Extravasation and hypersensitivity rescue plans are available Compliant Deficient N/A
Hazardous-drug handling requirements are followed Compliant Deficient N/A
Administration sequencing is clearly defined Compliant Deficient N/A
Patient and caregiver education is standardized Compliant Deficient N/A
Notes:

Parenteral Nutrition

Criterion text Compliant Deficient N/A
Standardized ordering templates are used Compliant Deficient N/A
Dosing weight and fluid goals are clearly identified Compliant Deficient N/A
Macronutrient and electrolyte limits are defined Compliant Deficient N/A
Compatibility and stability are reviewed Compliant Deficient N/A
Independent verification is used according to policy Compliant Deficient N/A
Final formulation matches the verified order Compliant Deficient N/A
Infusion rates and cycling instructions are clear Compliant Deficient N/A
Glucose and electrolyte monitoring requirements are defined Compliant Deficient N/A
Line and filter requirements are standardized Compliant Deficient N/A
Transition and discontinuation processes are defined Compliant Deficient N/A
Notes:

Epidural and Intrathecal Medications

Criterion text Compliant Deficient N/A
Route is prominently displayed Compliant Deficient N/A
Products are physically segregated from intravenous medications Compliant Deficient N/A
Route-specific connectors are used when available Compliant Deficient N/A
Prescribing is restricted to approved order sets Compliant Deficient N/A
Preparation occurs in pharmacy when feasible Compliant Deficient N/A
Independent verification is required according to policy Compliant Deficient N/A
Storage and transport controls reduce wrong-route risk Compliant Deficient N/A
Administration tubing and labels are route specific Compliant Deficient N/A
Monitoring requirements are defined Compliant Deficient N/A
Rescue and escalation guidance is available Compliant Deficient N/A
Notes:

Other Institution-Defined Medication

Institution-defined medication or class: ______________________________________________

Local medication-specific safeguards:

Notes: