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 opiates (61%).

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.