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ISMP 2007 Survey on HIGH-ALERT Medications: Differences Between Nursing and Pharmacy Perspectives Still Prevalent

ISMP extends sincere thanks to the 770 practitioners who completed our survey on high-alert medications between February and April 2007! High-alert medications are those 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 are clearly more devastating to patients. Those who participated in our survey will help inform our decisions as we update the ISMP list of high-alert medications. A discussion of the survey highlights follows. 

high-alert medication survey

Practitioners' views. Tables 1 and 2 show which drugs, based on our current list of high-alert medications and three new drugs for consideration, were most frequently and least frequently considered high-alert medications by our survey respondents. These findings were similar to responses we received during our 2003 survey on high-alert medications, with a few notable exceptions:

  • Epidural and intrathecal medications, added to ISMP's high-alert drug list after the 2003 survey, joined the top ten drugs that practitioners felt should be considered high-alert medications in the 2007 survey.
  • Three additional drugs added after the 2003 survey-colchicine injection, IV radiocontrast media, and oral methotrexate for non-oncologic use-are among the drugs least frequently considered high-alert medications; however, close to half of all respondents considered them to be high-alert medications in the 2007 survey.
  • The three new drugs added to the 2007 survey for consideration-epoprostenol, oxytocin, and promethazine IV-are among the medications least frequently considered high-alert medications; however, again, well more than half of all respondents felt they should be high-alert medications.
  • There was a sizable increase in the frequency with which respondents felt general anesthetics should be considered high-alert medications (from 77% in 2003 to 86% in 2007). Perhaps attention to the use of propofol outside of the anesthesia suite may have added to this increase.
  • There were sizable decreases between 2003 and 2007 in the frequency with which respondents believed hypertonic sodium chloride (from 91% to 83%) and warfarin (from 73% to 60%) should be considered high-alert medications. 

This last bullet point is interesting given that risk/quality/safety managers who responded to the survey placed both hypertonic sodium chloride and warfarin among the top 10 drugs that they felt should be considered high-alert medications. See Table 3 for details. high alert medicationsPerhaps these differences can be explained by the additional knowledge that risk/quality/ safety managers often have regarding the drugs that have caused patient harm. Frontline practitioners may not be privy to this information, which often stems from internal and external error reporting databases, reports of malpractice claims and judgments, patient complaints, and publications about sentinel events involving drugs.

Practice site adoption. Respondents also reported whether their practice sites treated each drug on the survey as a high-alert medication, with special precautions in place to prevent errors and harm. Tables 1 and 2 provide information regarding these findings, 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 categories considered high-alert medications in practice sites included:

  • parenteral chemotherapy (90%)
  • IV insulin (88%)
  • potassium chloride for injection concentrate (86%)
  • IV unfractionated heparin (80%)
  • epidural/intrathecal drugs (79%)
  • neuromuscular blocking agents (78%)
  • potassium phosphates injection (77%).   

The least common drugs or drug categories considered high-alert medications in practice sites included:

  • oral hypoglycemics (21%)
  • colchicine injection (29%)
  • epoprostenol (Flolan) (39%)
  • dialysis solutions, peritoneal and hemodialysis (40%)
  • IV adrenergic antagonists (41%)
  • IV radiocontrast agents (43%)
  • liposomal forms of drugs (44%).

Although the gap was sometimes fairly large between respondents' beliefs and practice site designation as a high-alert drug, the adoption of safety precautions for many of the specific drugs or drug classes in the survey generally increased between 2003 and 2007.

Differing views. As in the 2003 survey, some interesting differences emerged between nurses' and pharmacists' perceptions regarding which drugs they considered high-alert medications. With only two exceptions-concentrated sodium chloride and subcutaneous insulin-nurses more frequently identified the drugs listed in the survey as high-alert medications than did pharmacists. See Table 4 (in the PDF version of the newsletter) for details.

For certain medications, including two of the new drugs added in the 2007 survey, the differences were large:

  • 65% of nurses reported that IV radiocontrast agents should be considered high-alert medications, compared to 34% of pharmacists.
  • 73% of nurses believed that oxytocin should be a high-alert medication, but only 38% of pharmacists agreed.
  • 68% of nurses felt that epoprostenol should be a high-alert medication, compared to 45% of pharmacists.

Using the survey findings. ISMP will be compiling an updated list of high-alert medications based on these survey findings, along with evidence from various medication error reporting programs to which ISMP has access, and the opinions of safety experts throughout the US. We will then revise the list as necessary, publish it in this newsletter, and post it on our website. Meanwhile, we hope you will use these survey findings to stimulate discussions about high-alert medications in your organization. Discussions focusing on nursing and pharmacy perspectives may prove to be especially worthwhile, including exploration of the differences in opinion about which drugs should be considered high-alert medications. Differences between practitioners' beliefs that a drug should be a high-alert medication and practice site adoption of safety precautions for the drug might also be useful. As we first mentioned in our January 11, 2007 newsletter, ISMP will continue throughout the year to bring readers key information about selected high-alert medications and how to reduce patient harm when prescribing, dispensing, and administering these drugs.