High Alert Medication Mitigation Strategies (HAMMS): A rapid realist review for assessing what works, how, and in what circumstances in a full service Irish acute hospital

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Abstract Introduction All medications have the potential to cause harm; however, some are prone to cause more serious harm than others - titled “high-alert medications”. High-alert medications are identified from national/international consensus and from local patient incidents. Safeguarding of high-alert medications through mitigation strategies is complex and can represent a multi-faceted approach; international consensus, public guidance and local data inform interventions to reduce the risk of error. Realism can explore complex interventions, whereby rapid realist reviews are used when the evidence is required for a local intervention, and the results are not required to be relevant in other situations. Aim This rapid realist review aimed to present an evidence-informed approach of high-alert medication mitigation strategies within an acute hospital, how they work, why and the specific circumstances they work in. Methods Realist methodologies explores the context (C) of strategies/interventions (I) and the mechanisms (M) by which they operate to impact outcomes (O), which in this case is to reduce the risk of errors associated with high-alert medications. Audit data and stakeholder discussion informed the development of an initial programme theory. A rapid literature review across four databases was then conducted to test the initial programme theory, where evidence of how interventions work to reduce errors in specific contexts was extracted using Microsoft Excel®. Papers from initial rapid reviews and iterative searches were assessed by relevance and rigour through NVivo12® software, until theoretical saturation of the programme theory was reached, and the development of a modified programme theory occurred. Results Thirty-two papers were included in the final synthesis. Specific to the institution, employing redundancies, standardisation, warning labels and automation were the most commonly applicable interventions related to mitigating the risk of high-alert medications. Governance, confidence, limiting access and engagement, among other adaptive and responsive mechanisms are needed to facilitate these interventions. Influence is spread across organisational, ward and individual perspectives for increasing access to information. Based on audited data, insulin medication management represented a specific area for focus; therefore, a list of ten recommendations were drawn up using guiding principles from realist findings. Conclusion A suite of high- to low-leverage strategies related to high-alert medications, applied within specific contexts, could be adopted within the institutions current infrastructure. Further research is needed to evaluate the adoption of the strategies to determine their success and validate the data. Rapid realist reviews are useful methods in capturing complex interventions within specific institutions in a time-sensitive manner.

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