From the October 16, 2003 issue
Thanks to more than 350 practitioners who completed
our survey on high-alert medications during August and September
2003! High-alert medications are drugs that bear a heightened
risk of causing significant harm when they are used in error.
Although mistakes may or may not be more common with these
drugs, the consequences of an error with these medications
are clearly more devastating to patients. In many cases,
survey respondents agreed on which medications fell into
this category (see Tables 1 and 2 below for examples of
drugs most frequently, and least frequently, considered
high-alert medications). However, there were some interesting
differences between nurses' and pharmacists' perceptions
regarding which drugs they considered to be high-alert medications.
The survey also uncovered some fairly large gaps between
the drugs that respondents felt were high-alert medications,
and whether their practice sites had adopted them as high-alert
medications, with special precautions in place.
Differing views. With few exceptions, nurses more
frequently identified the drugs listed in the August 21st
survey as high-alert medications than did pharmacists. For
certain medications, the differences were rather large.
For example, 81% of nurses felt that IV adrenergic antagonists
were high-alert medications, but only 43% of pharmacists
felt the same way. Sizable differences were also noticed
with IV adrenergic agonists (nurses 92%, pharmacists 63%),
oral or IM narcotics (nurses 69%, pharmacists 46%), liposomal
forms of drugs (nurses 68%, pharmacists 39%), and several
other medications (see Table 3 below). On the other hand,
pharmacists clearly felt more strongly than nurses that
hypertonic sodium chloride (pharmacists 94%, nurses 73%),
warfarin (pharmacists 75%, nurses 59%), and subcutaneous
insulin (pharmacists 72%, nurses 63%) were high-alert medications.
Practice site adoption. Most respondents reported
that parenteral chemotherapy (90%) and IV potassium chloride
concentrate (90%) were considered high-alert medications,
with special precautions in place, at their practice sites.
However, the number of facilities with precautions in place
for other products listed on the survey dropped quickly,
even for drugs like IV heparin (80%), IV insulin (78%),
neuromuscular blocking agents (78%), IV conscious sedation
agents (64%), IV thrombolytics (63%), and IV narcotics and
Additionally, survey findings showed some rather large differences
between respondents' beliefs regarding drugs they would
consider high-alert medications, and actual adoption of
these drugs as high-alert medications, with safeguards,
at their practice sites. For example, while 69% of all respondents
felt that IV adrenergic agonists were high-alert medications,
only 47% reported that their practice sites had adopted
special precautions for using these products. Similar differences
were found with liposomal forms of drugs (individuals 45%,
practice site adoption 23%); oral conscious sedation agents
for children (individuals 68%, practice site adoption 46%);
IV inotropic drugs (individuals 67%, practice site adoption
45%); warfarin (individuals 73%, practice site adoption
53%); and glycoprotein IIb/IIIa inhibitors (individuals
63%, practice site adoption 44%). There was no evidence
that hospitals had adopted any of the drugs on the survey
as a high-alert medication at a rate higher than respondents'
collective beliefs that it was warranted.
Using the survey findings. Based on the survey findings,
as well as evidence from the USP-ISMP Medication Errors
Reporting Program and medication safety experts, we will
be compiling an updated list of high-alert medications,
which will be published in the newsletter later this year.
Meanwhile, we hope you will use these survey findings (see
the full results at www.ismp.org/Surveyhosp1.asp)
to stimulate discussion about high-alert medications in
your organization. In particular, exploring the differences
that we identified between nursing and pharmacy perspectives
regarding which drugs should be considered high-alert medications
may prove to be a worthwhile endeavor. In 2004, we plan
to issue a series of surveys to learn about the special
precautions that are in place in healthcare organizations
for several of these high-alert medications.