Results of ISMP survey on High-Alert Medications: Differences between nursing, pharmacy, and risk/quality/safety perspectives
February 9, 2012

ISMP extends thanks to the 772 practitioners who completed our survey on high-alert medications between October 2011 and February 2012. We sincerely appreciate your input as we update the ISMP List of High-Alert Medications for Acute Care Settings in 2012. High-alert medications can be defined as those medications that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of errors are often harmful, sometimes fatal, to patients. Highlights from the survey follow.

Practitioners’ views. Table 1 (in the PDF version) shows the percent of respondents who consider the drugs in our survey to be high-alert medications. These findings are similar to responses we received during our 2007 survey on high-alert medications (, with a few notable exceptions:

  • Antithrombotics rose from the eighth to the third most frequent medication/class considered a high-alert medication by respondents.
  • There was a sizable increase between 2007 (76%) and 2012 (86%) in the percent of respondents who felt subcutaneous insulin should be considered a high-alert medication.
  • The largest change in the percent of respondents who felt a medication should be considered high-alert was observed with IV oxytocin; 58% felt it was a high-alert drug in 2007; 71% consider it a high-alert drug in 2012.
  • The percent of respondents who felt parenteral nutrition should be considered a high-alert medication rose from 55% in 2007 to 64% in 2012.
  • Sterile water for injection, inhalation, and irrigation in containers of 100 mL or greater—an addition to the list in 2007—was the drug least frequently considered a high-alert medication.

Chemotherapy topped the list in both 2007 and 2012, with IV insulin, antithrombotic agents, epidural/intrathecal medications, and potassium chloride injection rounding out the top five medications considered by respondents to be high-alert medications. Subcutaneous insulin and IV opioids ranked ninth and twelfth respectively, although at least 80% of all respondents believe these medications should be considered high-alert medications. Joining sterile water for injection, inhalation, and irrigation (100 mL or greater) as the least likely to be considered high-alert medications were oral hypoglycemics, liposomal medications and their counterparts, IV adrenergic antagonists, and IV promethazine.

Practice site adoption. Respondents also reported whether their practice sites treated each drug in the survey as a high-alert medication, with special precautions in place to prevent errors and harm. Table 1 (starting on page 1 in the PDF version) provides information regarding these findings as well, showing the differences between practitioners’ beliefs that the medication should be considered high-alert and practice site adoption of safety precautions for the drug.

The most common drugs or drug classes treated as high-alert medications in at least 80% of respondents’ practice sites included:

  • Chemotherapy, parenteral/oral (93%)
  • Antithrombotic agents (93%)
  • Insulin, IV (93%)
  • Potassium chloride injection (89%)
  • Insulin, subcutaneous (84%)
  • Neuromuscular blocking agents (83%)
  • Epidural/intrathecal medications (82%)
  • Potassium phosphate injection (80%).

The least common drugs or drug classes treated as high-alert medications in less than half of respondents’ practice sites included:

  • Sterile water for injection/inhalation/ irrigation in containers of 100 mL or greater (24%)
  • Hypoglycemics, oral (31%)
  • Liposomal forms of drugs and conventional counterparts (38%)
  • Adrenergic antagonists, IV (44%)
  • Dialysis solutions (44%)
  • Radiocontrast agents, IV (46%)
  • Epoprostenol, IV (47%)
  • Promethazine, IV (49%).

For every drug in the survey, more respondents believed the drug should be considered a high-alert medication than actual practice site adoption of the drug as a high-alert medication with safety precautions in place. The gap between respondents’ beliefs and practice site adoption was often large, particularly for cardioplegia solutions, hypertonic dextrose greater than 20%, dialysis solutions, epoprostenol, and anesthetic agents. The gap between respondents’ beliefs and actual practice site adoption was lowest for insulin (IV and subcutaneous), antithrombotics, potassium chloride injection, and methotrexate (oral, non-oncologic use). The adoption of safety precautions for most of the drugs/classes of drugs in the survey increased between 2007 and 2012, with the largest gains seen with IV oxytocin, antithrombotics, subcutaneous insulin, methotrexate (oral, non-oncologic use), and narcotics and opioids (all routes).  

Differing views. As in the 2007 survey, interesting differences emerged between nurses’ and pharmacists’ perceptions regarding which drugs they considered to be high-alert medications (Table 2 in the PDF version). In general, nurses more frequently identified the drugs in the survey as high-alert medications than pharmacists, particularly with these medications:

  • Adrenergic antagonists, IV (32% more than pharmacists)
  • Oxytocin, IV (30% more)
  • Dialysis solutions (26% more)
  • Radiocontrast agents, IV (23% more)
  • Antiarrhythmics, IV (18% more)
  • Nitroprusside sodium, IV (17% more)

With these drugs, nurses may feel more vulnerable to harmful errors, particularly since the pharmacy may not prepare all doses/infusions of these medications, thus requiring nurse preparation. Nurses may also have witnessed transient harm with these drugs in critical care settings, providing greater awareness of the potential for harm associated with these drugs.

On the other hand, pharmacists identified the drugs listed on the next page as high-alert medications more often than nurses:

  • Sterile water for injection, inhalation, and irrigation (containers 100 mL or greater) (32% more than nurses)
  • Sodium chloride injection, greater than 0.9% concentration (23% more)
  • Methotrexate, oral, non-oncologic uses (19% more)
  • Promethazine, IV (10% more)

For these drugs, findings suggest that perhaps pharmacists have greater awareness of the risk of harm associated with errors involving these medications than nurses.

Risk/quality/safety managers identified these drugs as high-alert medications more often than either pharmacists or nurses:

  • Moderate sedation, IV and oral for children (10% more than nurses or pharmacists)
  • Inotropic medications, IV (14% more)
  • Promethazine, IV (12% more)
  • Magnesium sulfate injection (8% more)

Perhaps these differences can be explained by the knowledge that risk/quality/safety managers often have regarding the drugs that have caused patient harm, which often stems from internal and external error-reporting databases, malpractice claims and judgments, patient complaints, and publications about sentinel events.

Suggested additions. In the survey, ISMP provided five drugs/classes of drugs to consider for addition to the ISMP List of High-Alert Medications for Acute Care Settings (Table 3 in the PDF version). These drugs—antiretroviral agents, arginine, carBAMazepine, colistin, and metFORMIN—received an affirmative response from about one-third of respondents. We also asked respondents to tell us if they thought fentaNYL transdermal, HYDROmorphone, and methadone should be given special emphasis, although each resides within a class of drugs already considered high-alert medications. Nearly three-quarters of respondents agreed to this with HYDROmorphone, and about two-thirds agreed to this with methadone and fentaNYL patches.  

Respondents also offered suggestions for other medications to be added to our list of high-alert medications. We appreciate all the thought that went into making these suggestions. However, in an effort to keep the list manageable, we narrowed the potential additions to a few medications—vasopressin, dexmedetomidine, and special emphasis on U-500 insulin—which we will be evaluating during the next few weeks. We will also determine whether any drugs currently on the list should be removed.

Using the survey findings. ISMP will be updating our list of high-alert medications based on these survey findings, along with evidence from medication error reporting programs to which we have access, opinions of safety experts, and published research that identifies the drugs associated with harmful errors. We will publish the updated list in this newsletter and post it on our website in March 2012. Meanwhile, we hope you will use these survey findings to encourage discussions about high-alert medications in your organization. Focusing on differing nursing and pharmacy perspectives regarding which drugs should be considered high-alert medications may prove especially worthwhile, as would learning about gaps in practice site adoption of safety precautions for drugs staff perceive to be high-alert medications.
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