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High Alert Medications

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Institute Insti tute for Safe Medica Medication tion Practi Practices ces

ISMP’s  List of  High-Alert  Medications    Medications 

H

igh-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 an error are clearly more devastating to patients. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors. This may include strategies like improving access to information about

these drugs; limiting access to high-alert medications; using auxiliary labels and automated alerts; standardizing the ordering, storage, preparation, and administration of these products; and employing redundancies such as automated or independent doublechecks when necessary. (Note: manual independent double-checks are not always the optimal error-reduction strategy and may not be practical for all of the medications on the list).

Classes/Categories of Medications

Specific Medications

adrenergic agonists, agonists, IV (e.g., EPINEPHrine, phenylephrine, norepinephrine)

colchicine injection***

adrenergic antagonists, antagonists, IV I V (e.g., propranolol, metoprolol, labetalol)

epoprostenol epoprosten ol (Flolan), IV

anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)

insulin, n, subcutaneous and IV

antiarrhythmics, antiarrhyt hmics, IV (e.g., lidocaine, amiodarone)

magnesium magnesiu m sulfate injection

antithrombotic agents (anticoagu antithrombotic (anticoagulants), lants), including warfarin, low-mole low-molecular-wei cular-weight ght heparin, IV unfractionated onated heparin, Factor Xa inhibitors tors (e.g., fondaparinux), direct thrombin inhibitors (e.g., argatroban, bivalirudin, bivalirudin, dabigatran etexilate, lepirudin), thrombolytics thrombolyt ics (e.g., alteplase, alteplase, reteplase, tenecteplase), tenecteplase), and glycoprotein IIb/I IIa inhibitors (e.g., eptifibatide)

methotrexate, methotrexat e, oral, non-oncologic ogic use

cardioplegic solutions

nitroprusside nitroprus side sodium for injection

chemotherapeutic chemothera peutic agents, parenteral and oral

potassium potassiu m chlorid chloridee for injection concentrate

dextrose, hypertonic, 20% or greater 

potassium phosphates injection

dialysis solution solutions, s, peritoneal and hemodialy hemodialysis sis

promethazine, ne, IV

epidural or intratheca intrathecall medicatio medications ns

sodium chloride for injection, hypertonic (greater than 0.9% concentration)

hypoglycemics, oral

sterile water for injectio injection, n, inhalation, and irrigation (excluding pour bottles) in containers of 100 mL or more

inotropic medicatio medications, ns, IV (e.g., digoxin, milrinone) liposomal forms of drugs (e.g., liposomal amphotericin B) and conventional counterliposomal parts (e.g., amphotericin B deoxycholate) ate)

opium tincture oxytocin, IV

*** Colchicine injection is no longer available in the United States. It should no longer  be used.

Background

moderate sedation agents, IV (e.g., midazolam) moderate sedation agents, oral, for childre childrenn (e.g., chloral hydrate) narcotics/opiates, IV, transdermal, and oral (including liquid concentrates, immediate narcotics/opiates, and sustained-release formulations) neuromuscular neuromusc ular blocking agents (e.g., succinylcholine, ne, rocuronium rocuronium,, vecuroniu vecuronium) m) radiocontrast radiocontr ast agents, IV total parenteral nutrition on solution solutionss

© ISMP 2011. Permission is granted to reproduce material with proper attribution for internal use within healthcare organizations. organizations. Other reproduction is prohibited without written permission from ISMP. Report actual and potential medication er rors rors to the ISMP National ISMP National Medication on Errors Reporting Program (ISMP MERP) via the Web at at www.ismp.org  www.ismp.org or  or by calling 1-800-FAIL-SAF(E).

Based on error reports submitted to the ISMP National Medication Errors Reporting Program, reports of harmful errors in the literature, and input from practitioners and safety experts, ISMP created and periodically updates a list of potential high-alert medications. medication s. During February-April 2007, 2007, 770 practitio practitioners ners responded to an ISMP IS MP survey designed to identif identifyy which medication medicationss were most frequently considered high-alert ert drugs by individuals duals and organizations. ons. Further, to assure relevance and completeness, the clinical staff at ISMP, members of our advisory board, and safety experts throughout the US were asked to review the potential list. This list of drugs and drug categories reflects the collective thinking of all who provided input.

www.ismp.org

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