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ISMP extends our thanks to more than 200 respondents consisting of pharmacists
(65%), nurses (31%), and others (4%) who completed our survey on high-alert
medications between May and June 2014. We sincerely appreciate your input as we
update theISMP List of High-Alert Medications for Acute Care Settings. High-alert
medications are drugs 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.
The 2014 survey asked practitioners whether theyconsidered the drugs on ISMPs list to
be high-alert medications, whether their practice sites considered the drugs to be high-
alert medications, and whether their practice sites had implemented effective
precautions for the drugs identified as high-alert medications. Highlights from the survey
follow.
Practitioners Views
Overall results. Table 1 shows the percent of respondents who considered the drugs in
our survey to be high-alert medications. These are the medications and classes of
medications that are currently on the ISMP List of High-Alert Medications for Acute
Care Settings. While chemotherapy topped the list in prior surveys conducted in 2007
(www.ismp.org/sc?id=380) and 2012 (www.ismp.org/sc?id=381), IV insulin and
anticoagulants were most frequently considered high-alert medications by respondents
of this years survey. Rounding out the top five high-alert medications in 2014 were
chemotherapy, neuromuscular blocking agents, and epidural/intrathecal medications.
Concentrated electrolyte solutions, including potassium chloride injection concentrate,
hypertonic sodium chloride injection (greater than 0.9% concentration), potassium
phosphate injection, and magnesium sulfate injection ranked sixth, seventh, eleventh,
and twentieth, respectively. Subcutaneous insulin ranked ninth, and injectable opioids
ranked twelfth. Joining oral hypoglycemics as the least likely to be considered high-alert
medications were sterile water for injection, inhalation, and irrigation (100 mL or greater);
IV beta-adrenergic antagonists; dialysis solutions; and radiocontrast agents.
Comparison to 2012 results. Among all 39 drugs/drug classes on ISMPs current list,
the findings were similar to our 2012 survey for 22 of the drugs. However, for 14 of the
39 drugs/drug classes, significantly fewer 2014 respondents felt these drugs should be
considered high-alert medications than the 2012 respondents. The reduction was at
least 5 percentage points, with the largest differences as follows:
Cardioplegia solution (considered a high-alert drug by 80% in 2012, 60% in 2014)
Beta-adrenergic antagonists, IV (54% in 2012, 35% in 2014)
Radiocontrast agents, IV (58% in 2012, 42% in 2014)
Inotropic medications, IV (66% in 2012, 53% in 2014)
Antiarrhythmics, IV (70% in 2012, 58% in 2014)
Nitroprusside sodium, IV (76% in 2012, 65% in 2014)
Dextrose, hypertonic, 20% or greater (74% in 2012, 64% in 2014)
Oxytocin, IV (71% in 2012, 61% 2014)
Thrombolytics (96% in 2012, 87% 2014)
While there were very small increases between 2012 and 2014 regarding individual
beliefs that a drug was a high-alert medication for 9 of the 39 drugs/drug classes,
increases of any significance were observed for only 2 drugs:
Overall results. Table 1 also shows whether respondents practice sites considered the
39 drugs/drug classes to be high-alert medications, whether there were specific
precautions in place at their practice sites, and whether respondents thought the
precautions were effective. More than 90% of respondents reported that their practice
sites considered anticoagulants (96%), IV insulin (95%), and chemotherapy (93%) to be
high-alert medications. More than 80% of the practice sites considered potassium
chloride injection concentrate (89%), subcutaneous insulin (85%), and neuromuscular
blocking agents (86%) to be high-alert medications. About three-quarters of practice
sites considered epidural/intrathecal medications (76%), hypertonic sodium chloride
injection (75%), and potassium phosphate injection (74%) to be high-alert medications.
About two-thirds (67%) of practice sites considered injectable opioids to be high-alert
medications. The drugs least frequently considered high-alert drugs at practice sites
included oral hypoglycemics (18%); sterile water for injection, inhalation, or irrigation
(18%); dialysis solutions (22%); and liposomal drugs and conventional counterparts
(28%).
The only drug that increased more than 3 percentage points between 2012 and 2014
was hypertonic sodium chloride for injection (70% in 2012, 75% in 2014).
If there were special precautions in place for drugs considered high-alert medications,
respondents often felt the precautions were effective. For 34 of the 39 drugs, 90% or
more felt the precautions were effective. The lowest levels of confidence regarding
precautionary measures were associated with the remaining 5 high-alert medications:
Differing Views
As with the 2012 survey, differences were again apparent between nurses and
pharmacists perceptions regarding which drugs they considered to be high-alert
medications (Table 1). In general, nurses more frequently identified the drugs in the
survey as high-alert medications than pharmacists, particularly with these drugs/drug
classes:
With these drugs, nurses may feel more vulnerable to harmful errors than pharmacists,
particularly if the nurse is responsible for the selection and/or preparation of
doses/infusions. Nurses may also have witnessed transient patient harm with these
drugs in patient care areas, enhancing awareness of the potential for harm with the
drugs.
On the other hand, the following examples are drugs that pharmacists identified as high-
alert medications more often than nurses:
Sterile water for injection, inhalation, and irrigation (44% pharmacists, 14%
nurses)
Methotrexate, oral, non-oncologic use (71% pharmacists, 51% nurses)
Sodium chloride injection, hypertonic, greater than 0.9% (91% pharmacists, 76%
nurses)
Liposomal drugs and conventional counterparts (52% pharmacists, 39% nurses)
Factor Xa inhibitors (80% pharmacists, 67% nurses)
Potassium chloride injection concentrate (95% pharmacists, 85% nurses)
Potassium phosphate injection (81% pharmacists, 71% nurses)
These findings suggest that perhaps pharmacists have greater awareness of the risk of
harm associated with errors for these drugs than nurses. Perhaps some of these
differences can also be explained by the fact that pharmacists may have sole access to
several of the products for use during IV admixture.
Suggested Additions
In the survey, ISMP provided eight drugs/drug classes or other products to consider for
addition to, or special emphasis on the ISMP List of High-Alert Medications for Acute
Care Settings (Table 1). Insulin U-500 received an affirmative response from 98% of
respondents; 92% of these respondents said their practice sites already consider this a
high-alert drug, and of this group, 90% have initiated special precautions to prevent
errors with insulin U-500. Half of the respondents also reported that
subcutaneous EPINEPHrine is considered a high-alert drug at their practice sites. ISMP
plans to add these two drugs to its high-alert medications list.
Conclusion
Again, ISMP thanks those who took the time to complete our survey on high-alert
medications. Nonetheless, we are disappointed in the lower-than-usual response to this
survey. In 2012, we received almost 800 survey responses. We are also concerned
about what appears to be a significant downward trend in including many of the drugs on
ISMPs list of high-alert medications on practice site lists. It appears that precautions are
frequently established and felt to be effective if a drug is included on the practice site list.
But there seems to be numerous medications that no longer appear on practice site lists,
despite long-standing risks that have led to catastrophic errors. We realize that a
practice site list may not include all the medications on the ISMP list because they may
not be used in a particular setting (e.g., chemotherapy). However, a reduction in practice
sites that consider an injectable opioid or thrombolytics to be high-alert drugs is
concerning.
Although not covered in this summary of findings, there are also significant gaps
regarding the medications healthcare practitioners believe should be high-alert
medications and those included on practice site lists. For example, while 78% of
respondents felt opioids (IM/IV) were high-alert medications, only 67% of respondents
reported that their practice sites consider this class of drugs to be high-alert medications.
We urge all organizations to 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 to enhance understanding of the perceived risks by each
group. It would also be useful to evaluate any gaps in practice site adoption of safety
precautions for drugs that staff perceive to be high-alert medications.