High-alert medications

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 an error are clearly more devastating to patients. The Institute for Safe Medication Practice (ISMP) has assembled a list to identify which medications require special safeguards to reduce the risk of errors. This may include strategies such as standardizing the ordering, storage, preparation, and administration of these products; improving access to information about these drugs; limiting access to high-alert medications; using auxiliary labels and automated alerts; and employing redundancies such as automated or independent double-checks 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 high-alert medications
The following list of classes/categories of high-alert medications come form the ISMP.


 * adrenergic agonists, IV (e.g., EPINEPHrine, phenylephrine, norepinephrine)
 * adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)
 * anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)
 * antiarrhythmics, IV (e.g., lidocaine, amiodarone)
 * antithrombotic agents, including:
 * anticoagulants (e.g., warfarin, low-molecular-weight heparin, IV unfractionated heparin)
 * Factor Xa inhibitors (e.g., fondaparinux)
 * direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran etexilate, lepirudin)
 * thrombolytics (e.g., alteplase, reteplase, tenecteplase)
 * glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)
 * cardioplegic solutions
 * chemotherapeutic agents, parenteral and oral
 * dextrose, hypertonic, 20% or greater
 * dialysis solutions, peritoneal and hemodialysis
 * epidural or intrathecal medications
 * hypoglycemics, oral
 * inotropic medications, IV (e.g., digoxin, milrinone)
 * insulin, subcutaneous and IV
 * liposomal forms of drugs (e.g., liposomal amphotericin B) and conventional counterparts (e.g., amphotericin B desoxycholate)
 * moderate sedation agents, IV (e.g., dexmedetomidine, midazolam)
 * moderate sedation agents, oral, for children (e.g., chloral hydrate)
 * narcotics/opioids
 * IV
 * transdermal
 * oral (including liquid concentrates, immediate and sustained-release formulations)
 * neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)
 * parenteral nutrition preparations
 * radiocontrast agents, IV
 * sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers of 100 mL or more
 * sodium chloride for injection, hypertonic, greater than 0.9% concentration

Specific high-alert medications
The following list of specific high-alert medications come form the ISMP.


 * epoprostenol (Flolan), IV
 * magnesium sulfate injection
 * methotrexate, oral, non-oncologic use
 * opium tincture
 * oxytocin, IV
 * nitroprusside sodium for injection
 * potassium chloride for injection concentrate
 * potassium phosphates injection
 * promethazine, IV
 * vasopressin, IV or intraosseous

Background
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. During October 2011-February 2012, 772 practitioners responded to an ISMP survey designed to identify which medications were most frequently considered high-alert drugs by individuals and organizations. 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.