To ensure the safe infusion of high-alert medications, titrations need to be protected from harmful dosing changes, according to a poster presentation at the 2017 ASHP Midyear Clinical Meeting and Exhibition.

In the study presented, infusion pump data for 45 hospitals were analyzed, including a total of 20,542 infusion pumps with 444,643 titration programming events from 15 high-alert IV medications. The data were obtained between October 2014 and July 2015.

Up to 90% of pump programming events on infusion of high-alert drugs are titrations after the infusions are started, according to the authors, which creates opportunities for programming errors. In some cases, titration programming may not be protected by traditional dosing limits of a smart pump drug library or EMR system, which can lead to harmful dosing changes that may be missed.  

The authors analyzed the titrations of each medication for incremental dose changes, comparing the common dose changes and the dosing limits configured for each medication. According to the results, 92.5% of titrations programmed for 14 high-alert medications were incremental dose increases of 100% or less and 93% of all heparin titrations were dose increases of 40% or less.  

According to the data, common titrations of high-alert medications demonstrated incremental changes that fall within common dose limit range. The authors noted that accidental titration misprogramming could result in a harmful dose change that falls within the “soft” dosing range of drug library dosing range limits.

To maximize safety and prevent errors with the infusion of high-alert medications, the authors recommended that:
  • Titratable medication orders must include the starting dose, titration dose increments, titration timeframes, maximum dose, and clinical endpoints.
  • Infusion systems should be designed with safety parameters for titration programming.
Features such as built-in titration error prevention, as used in the Sigma Spectrum Infusion System, can further assist health care professionals in protecting high-risk infusions during titrations, as well as the use of drug libraries to alert of potential errors prior to starting an infusion.

All authors are affiliated with Baxter Healthcare Corporation. 


Hoh T, Martin A. Titration programming: Don’t roll the dice. Presented at ASHP Midyear 2017 Clinical Meeting and Exhibition.