January 11, 2024 | Volume 29 ■ Issue 1

High-alert medication list for acute care settings

updated for 2024 B. Braun potassium chloride for injection
High-alert medications are an essential component of drug therapy. However, while concentrate pharmacy bulk package
errors with these products are not necessarily more common, the consequences almost infused into patient. A hospital
are often quite harmful and can even be fatal. To reaffirm and identify possible reported a close call with two high-alert
additions or deletions to our high-alert medication list, we recently reviewed medications when potassium chloride for
reports submitted to the ISMP National Medication Errors Reporting injection concentrate (500 mEq/250 mL) was
Program (ISMP MERP), clinical and safety literature, and input that we received found in the heparin injection (25,000 units/
from US medication safety experts. In addition, between September and October 250 mL) bin of an automated dispensing
2023, ISMP conducted a survey on high-alert medications in acute care settings. cabinet (ADC) on a nursing unit. Both products,
made by B. Braun, look similar and come in a
The first list of high-alert medications was published in 1989 (Davis NM, Cohen MR. Today’s 250 mL EXCEL plastic bag with blue and red
poisons: how to keep them from killing your patients. Nursing. 1989;19[1]:49-51). That initial list labeling (Figure 1). Fortunately, a nurse caught
included six medications that are still on ISMP’s list today—intravenous (IV) lidocaine, vinCRIS- the error after removing the bag's overwrap and
tine, sodium chloride for injection greater than 0.9%, morphine injection, insulin, and potassium scanning the barcode prior to administration.
chloride for injection concentrate. In this newsletter, we report the results of our recent survey and
compare them to a survey we conducted in 2018. We will also discuss changes we made to the list.
The updated ISMP List of High-Alert Medications in Acute Care Settings can be found on the
last page of this newsletter and on our website at: www.ismp.org/node/103.

2023 Findings

Respondent profile. ISMP extends our thanks to nearly 100 practitioners who validated our ISMP
List of High-Alert Medications in Acute Care Settings. Most practitioners were pharmacists
(85%) working in an inpatient pharmacy (63%), although we also heard from others (e.g., nurses,
risk/quality/safety managers, pharmacy technicians).

Drugs considered high-alert medications. Table 1, on page 3, shows the drugs on the 2018
ISMP List of High-Alert Medications in Acute Care Settings, and the percent of respondents
who considered these to be high-alert medications in 2018 and 2023. Half or more of the 2023
respondents thought that all of the drugs on our list were high-alert medications except IV
adrenergic antagonists (49%) as well as oral sulfonylurea hypoglycemics (39%), which was up Figure 1. A nurse found B. Braun’s heparin (left) and
from 29% in our 2018 survey. potassium chloride concentrate (right) in 250 mL EXCEL
bags in the same ADC bin.

In 2023, more than 80% of respondents thought these medication classes or specific drugs were The organization purchased B. Braun’s heparin
high-alert medications: due to a supply shortage from their typical
manufacturer. Similar to concerns that we
■ U-500 insulin (100%)
have previously published (www.ismp.org/
■ potassium chloride for injection concentrate (100%) node/80419), the organization noted that a
■ epidural and intrathecal medications (100%) seam on the overwrap of B. Braun premixed
bags obscures the already difficult-to-scan
■ sodium chloride for injection, greater than 0.9% (100%) white barcode on the clear bag, resulting in the
■ chemotherapeutic agents, parenteral and oral (98%) inability to scan the product in the pharmacy
■ insulin, subcutaneous and IV (98%) prior to dispensing and when filling the ADC.
Since this event, the reporting organization has
■ neuromuscular blocking agents (98%) implemented a process in which, in addition
■ antithrombotic agents (96%) to the manufacturer-supplied auxiliary label,
continued on page 2 — High-alert medication list > continued on page 2 — >
 January 11, 2024 | Volume 29 ■ Issue 1 | Page 2

> High-alert medication list — continued from page 1 cont'd from page 1

■ potassium phosphates injection (93%) the pharmacy applies a pharmacy-generated

■ methotrexate, oral, nononcologic use (93%) barcode to the potassium overwrap bags
to facilitate scanning. The organization is
■ epoprostenol (e.g., Flolan), IV (90%)
also storing the potassium in the controlled
■ opioids, all routes of administration (e.g., oral, sublingual, parenteral, transdermal) (88%) substance storage vault in the pharmacy.
■ parenteral nutrition preparations (82%) They are planning to purchase heparin from
a different manufacturer once the shortage is
Possible additions and changes. ISMP asked for feedback about one possible addition, resolved, which we would also recommend if
tranexamic acid injection, to the ISMP list, upon which about half (49%) of respondents agreed using these products.
that it should be added to the list.
In May 2022, we issued a National Alert
Comparison between 2023 and 2018 Network (NAN) alert (www.ismp.org/
node/31719), with recommendations to pre-
Differences between 2023 and 2018 findings. Prior to 2023, ISMP last conducted a survey on vent an error with the new presentation of B.
high-alert medications in acute care settings in 2018 (Table 1, on page 3), after which we updated Braun potassium chloride for injection concen-
our list based in part on the survey results. trate pharmacy bulk package. The product was
formerly available in glass containers, which
Compared to 2018, the drugs listed below had the largest increase in the percentage of respondents looked different than other premixed products,
who consider them high-alert medications. but the company decommissioned its glass
manufacturing line in the first quarter of 2022.
■ sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers
of 100 mL or more (52% thought this was a high-alert medication in 2018, 77% in 2023) Organizations that use this product should
review the NAN Alert and take immediate
■ potassium phosphates injection (72% in 2018, 93% in 2023) steps to prevent a potentially fatal medication
■ epoprostenol (e.g., Flolan), IV (70% in 2018, 90% in 2023) error. This includes ensuring that only
pharmacy can purchase, store, and use this
■ methotrexate, oral, nononcologic use (74% in 2018, 93% in 2023)
product; segregating this product from other
■ oxytocin, IV (60% in 2018, 79% in 2023) similar-looking infusion bags in pharmacy
■ EPINEPHrine, IM, and subcutaneous (51% in 2018, 68% in 2023) storage; affixing auxiliary labels on the case
of the product and both sides of the overwrap
2023 Change to the ISMP List on bags; and scanning the barcode on the bag
(as well as the barcodes on all intravenous [IV]
Based on practitioner feedback, review of the literature and error reports, and input from our infusion bags to ensure none are potassium
clinical advisory board, ISMP has made the following change to its current ISMP List of High- chloride for injection concentrate).
Alert Medications in Acute Care Settings:
Both heparin and concentrated potassium
■ Tranexamic acid injection was added to our list under “specific medications.” Tranexamic chloride injections are high-alert medications
acid is an antifibrinolytic agent that is used in a variety of hemorrhagic conditions to control that can lead to serious harm when involved
bleeding, including postpartum hemorrhage. It works by preventing the breakdown of in medication errors. The US Food and Drug
fibrin, thus promoting clotting. Respondents shared that errors are often related to storage Administration (FDA) and the manufacturer
issues and mix-ups with look-alike medication vials, most often anesthetics that are also need to urgently address these long-standing
commonly stored in surgical and procedural locations. When accidentally administered via look-alike issues and scanning difficulties
a neuraxial route, tranexamic acid injection is a potent neurotoxin with a mortality rate of before any deaths are reported.
about 50% and is almost always harmful to the patient. Survivors of neuraxial tranexamic
acid often experience seizures, permanent neurological injury, and paraplegia (www.ismp. We reached out to B. Braun and they told us
org/ext/1139). ISMP has repeatedly warned against errors with tranexamic acid, including they have added a white two-dimensional
a feature article in the May 23, 2019, ISMP Medication Safety Alert! (www.ismp.org/ (2D) barcode to the left of the linear barcode
node/8706), and most recently a Worth repeating in the August 24, 2023 newsletter on some bags, which is not obstructed by the
(www.ismp.org/node/94378). ISMP also published a National Alert Network (NAN) overwrap seam and can be easier to scan.
warning on September 9, 2020 (www.ismp.org/node/20154). We recommended they use dark ink on white
backgrounds for all barcodes and consider
We also received suggestions to consider adding about a dozen other medications to our list, moving the 2D barcode away from the linear
including investigational medications, any controlled drugs, IV immunosuppressive agents, barcode to allow for proper scanning per FDA
hypotonic sodium chloride, naloxone, alprostadil, and tolvaptan. Of note, about half of the suggested guidance—Safety Considerations for Container
continued on page 3 — High-alert medication list > continued on page 3 — >
 January 11, 2024 | Volume 29 ■ Issue 1 | Page 3

> High-alert medication list — continued from page 2 cont'd from page 2

additions were already on our list (e.g., bivalirudin, heparin, alteplase, tenecteplase, intrathecal Labels and Carton Labeling Design to Minimize
medications). We greatly appreciate the suggestions that readers made for additions to the ISMP Medication Errors (www.ismp.org/ext/930).
list of high-alert drugs. Although other changes were not made at this time, we will continue to
monitor the suggested items and consider them for further assessment in our next survey. Fluorouracil cream—ensure formulation
corresponds to indication. In a large health
Table 1. Comparison of respondents who believe these drugs/categories are high-alert medications, system, staff recently uncovered several
2023 and 2018 prescribing errors related to confusion
between the 0.5% and 5% strengths of
Classes/Categories of Medications 2023 2018 fluorouracil cream. A pharmacist was
High-Alert (%) High-Alert (%)
reviewing a patient’s prescription for
U-500 insulin 100 96 fluorouracil cream 0.5% and saw that the
potassium chloride for injection concentrate 100 95 prescriber added a note stating, “ordering
epidural and intrathecal medications 100 93 5%.” The pharmacist clarified with the
sodium chloride for injection, greater than 0.9% 100 88 prescriber, who confirmed, that the patient
chemotherapeutic agents, parenteral and oral 98 99
required fluorouracil cream 5%.
insulin, subcutaneous and IV 98 98
There are several factors that increase the
neuromuscular blocking agents 98 97 risk of confusing these products. Aside from
antithrombotic agents 96 96 the 10-fold difference in strength, fluorouracil
potassium phosphates injection 93 72 is sometimes referred to as “5-FU,” which is
methotrexate, oral, nononcologic use 93 74 an error-prone abbreviation and, in this case,
epoprostenol (e.g., Flolan), IV 90 70 can add to the confusion by highlighting
the number five. Both medications have
opioids, all routes (e.g., oral, sublingual, parenteral, transdermal) 88 83
the same dosage form and share one of the
parenteral nutrition preparations 82 68 indications which can all contribute to mix-
cardioplegic solutions 80 73 ups. Fluorouracil cream 0.5% is indicated for
oxytocin, IV 79 60 the treatment of actinic or solar keratoses.
anesthetic agents, general, inhaled and IV 77 71 This strength utilizes a porous microsphere
sterile water for injection, inhalation, and irrigation (excluding pour bottles) 77 52
delivery system with sustained-release
in containers of 100 mL or more characteristics, so it is administered once
daily. Fluorouracil cream 5% is approved for
nitroprusside sodium for injection 71 59
actinic keratoses and basal cell carcinoma,
adrenergic agonists, IV 71 69 and is administered twice daily.
antiarrhythmics, IV 71 58
inotropic medications, IV 69 65 The event prompted this organization to
moderate sedation agents, IV 68 69 review hundreds of previously dispensed
EPINEPHrine, IM, and subcutaneous 68 51
fluorouracil cream prescriptions. In more
than 20 cases, they found the 0.5% cream
magnesium sulfate injection 68 64
was ordered and dispensed for patients with
promethazine injection* 67 56
cancer instead of the indicated 5% cream.
opium tincture 65 60 A lower than intended dose for a cancer
vasopressin, IV and intraosseous 64 57 indication may result in suboptimal control
dextrose, hypertonic, 20% or greater 62 72 of symptoms and disease progression. In the
moderate and minimal sedation agents, oral, for children† 59 73 reverse scenario, an overdose may result in
dialysis solutions, peritoneal and hemodialysis 56 50
the possibility of increased absorption if the
patient has ulcerated or inflamed skin.
liposomal forms of drugs and conventional counterparts 55 50
adrenergic antagonists, IV 49 57 Organizations should consult with oncology
sulfonylurea hypoglycemics, oral‡ 39 29 and dermatology specialists and evaluate
which strength(s) to carry on the formulary
*2023 survey specified IV only based on their patient population. If both
†2023 expanded to include minimal sedation agents formulations are required, store them in
‡2023 changed oral hypoglycemics to oral sulfonylurea hypoglycemics separate locations and consider adding
continued on page 4 — High-alert medication list > continued on page 4 — >

© 2024 Institute for Safe Medication Practices (ISMP). All rights reserved. Redistribution and reproduction of this newsletter, including posting on a
public-access website, beyond the terms of agreement of your subscription, is prohibited without written permission from ISMP.
 January 11, 2024 | Volume 29 ■ Issue 1 | Page 4

> High-alert medication list — continued from page 3 cont'd from page 3

Conclusion warning signs on storage bins to create

awareness about the differences. Ensure
Again, ISMP thanks all who took the time to provide us with feedback about additions or deletions order sentences include the appropriate
to our high-alert medication list. Our updated list can be found on our website at: www.ismp. dosing frequency (e.g., once-daily, twice-
org/node/103. We hope you will use this list to determine which medications require special daily) based on indication and automatically
safeguards to reduce the risk of errors in your organization. Safeguards may include strategies such link the corresponding product (e.g., 0.5%,
as limiting access to high-alert medications; employing clinical decision support and automated 5%) for pharmacy to dispense. Avoid
alerts; standardizing the ordering, storage, preparation, and administration of these products; using abbreviating drug names and use the full
redundancies such as automated or independent double checks when necessary; using auxiliary drug name in computer systems. Use barcode
labels; and improving access to information about these drugs. scanning prior to stocking, dispensing,
and administration. Coach prescribers to
avoid using notes or comments to modify
orders (i.e., do not select the 0.5% strength
with a note to dispense the 5% strength).
If a prescriber cannot find the desired
formulation/product, they should reach out
FDA requires updates to promethazine labeling to pharmacy for guidance. Educate staff
and patients about the differences between
Due to the risk of severe chemical irritation and tissue injuries related to intravenous (IV) fluorouracil 0.5% and 5% creams and to
administration of promethazine injection, the US Food and Drug Administration (FDA) is requiring confirm the indication prior to dispensing/
manufacturers to add administration recommendations to prescribing information as well as administration. Warn patients to keep
carton and container labels (www.ismp.org/ext/1288). The FDA recommends injection via deep these products away from pets who may
intramuscular administration instead of IV administration. If it must be administered IV, it should develop severe toxicity if they lick their
first be diluted and infused through an IV catheter inserted into a large vein, preferably through owner's skin (www.ismp.org/node/1493).
a central venous catheter. FDA specifically mentions that the drug should not be given via veins
in the hand or wrist.

ISMP first brought attention to this serious

issue in a 2006 article, Action needed
to prevent serious tissue injury with IV
promethazine (www.ismp.org/node/934). IV medication webinar
This topic received a lot of attention and Join us on February 6, 2024 for a FREE
included more stories about this serious webinar entitled Improving Safety,
issue (Figure 1). Efficiencies, and Reducing Waste with
Ready-to-Administer IV Medications: A
Then, in 2007, the drug was added to ISMP Roadmap to Success. Please visit: www.
List of High-Alert Medications in Acute ismp.org/node/108857.
Care Settings (www.ismp.org/node/103).
Promethazine injection is a vesicant that To subscribe: www.ismp.org/node/10
is highly caustic to the intima of blood Figure 1. A patient accidentally received promethazine via ISMP Medication Safety
vessels and surrounding tissue. Parenteral an arterial line in his wrist, leading to pain that he described Alert! Acute Care (ISSN
as “squeezing my thumb and index finger with pliers.” 1550-6312) © 2024
administration can result in severe The arterial line was quickly removed. Redness, pain, and Institute for Safe
tissue damage, regardless of the route of swelling extended from his fingers to his forearm. Believing Medication Practices
(ISMP). All rights
administration. However, inadvertent intra- the patient had developed a thrombus, his physician reserved. Redistribution and reproduction of this
arterial injection associated with IV use performed an embolectomy, but no clot was found. About a newsletter, including posting on a public-access website,
beyond the terms of agreement of your subscription, is
has resulted in significant complications, month after the event, the patient's gangrenous thumb and prohibited without written permission from ISMP. This is a
finger were amputated.
including burning pain, erythema, swelling, peer-reviewed publication.
severe spasm of vessels, thrombophlebitis, venous thrombosis, phlebitis, nerve damage, Report medication and vaccine errors to ISMP: Please
call 1-800-FAIL-SAF(E), or visit www.ismp.org/report-
paralysis, abscess, tissue necrosis, and gangrene. medication-error. ISMP guarantees the confidentiality of
information received and respects the reporters’ wishes
regarding the level of detail included in publications.
Although the labeling changes are a step in the right direction, we believe stronger action
Editors: Shannon Bertagnoli, PharmD; Ann Shastay,
is needed. For this reason, the ISMP Targeted Medication Safety Best Practices for MSN, RN, AOCN; Rita K. Jew, PharmD, MBA, BCPPS,
Hospitals, Best Practice #13 (www.ismp.org/node/160) recommends organizations eliminate FASHP; Editor Emeritus, Michael R. Cohen, RPh, MS,
ScD (hon), DPS (hon), FASHP. ISMP, 5200 Butler Pike,
injectable promethazine from the formulary. Plymouth Meeting, PA 19462. Email: [email protected];
Tel: 215-947-7797.

ismp.org consumermedsafety.org linkedin.com/company/ismp facebook.com/ismp1 medsafetyofficer.org

 January
January 11,13, 2022| Volume
2024 27■Issue
Volume29 Issue11 | Page
Page 5
7

Specialthanks
Special thankstotoour
our
2023
2021 MSOS MemberBriefings
MSOS Member BriefingsPresenters
Presenters
The Medication Safety Officers Society (MSOS) holds Member Briefings every other month on various medication safety topics. The
The
MSOSMedication
MemberSafety Officers
Briefings are Society
webinars(MSOS) holds Member
that feature Briefings every
three 10-minute other month
presentations onvolunteer
from various medication safety topics.
MSOS members The MSOSa
who highlight
project, initiative, or relevant medication safety topic. The goal is for participants to take the information presented andause
Member Briefings are webinars that feature three 10-minute presentations from volunteer MSOS members who highlight project,
it to
initiative, or relevant medication safety topic. The goal is for participants to take the information presented and use it
implement similar medication safety initiatives within their organization. At each Briefing, ISMP President Rita Jew or President Emeritus to implement similar
Michaelmedication safety initiatives
Cohen provided an updatewithin their own
on ISMP organization.
activities. At us
Please let each Member
know Briefing, ISMP President
([email protected]) if there isEmeritus Michael
a medication Cohen
safety alsoyou
topic provides
would
an update on ISMP activities. Please let us know ([email protected]) if there is a medication safety topic you would like to present (or see
like to present (or see presented) in 2024. We hope others will volunteer to present their work! To join the MSOS and attend the Member
presented) during a 2022 MSOS Member Briefing. We hope others can join us as presenters in 2022! To join the MSOS and attend the Member
Briefings,
Briefings, please visit: www.medsafetyofficer.org/user/register.
visit: www.medsafetyofficer.org/user/register. MSOS membership
MSOS membership and the
and the 2022 2024 Member
Member are FREE.are FREE.
Briefings Briefings
Production
Production of
of the
the MSOS
MSOS Member
Member Briefings
Briefings would
would not
not be
bepossible
possible without
without the
the assistance
assistance of
of voluntary
voluntary MSOS
MSOS member
member presenters.
presenters. ISMP
ISMP sincerely
sincerely
thanks
thanks all
all of
of the 2023 presenters who
2021 presenters and longtime ISMP
helped make Member Bob
thevolunteer, Feroli,
Briefings PharmD,medication
a valuable FASHP, forsafety
moderating theforsessions.
resource MSOS members.

Thank You!
Scott D. Alcott, MSN, RN, NEA-BC; Director of Nursing Education & Professional Development Safety Officer, Einstein Medical Center Montgomery,
Rachelle Albay, PharmD, CPPS; Kaiser Permanente, Los Angeles, CA
East Norriton, PA
Stephen Andrews, PharmD, BCPS, CPPS; University of Utah Health, Salt Lake City, UT
Lisa Asmar-Abdien, BS Pharm, MBA; Clinical Research Content, City of Hope Hospital & Healthcare, Duarte, CA
Silvana Balliu, PharmD; Cleveland Clinic, Cleveland, OH
Jessica Anderson, PharmD, BCPPS; PICU Clinical Pharmacy Specialist, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
Stacy Carson, PharmD, BCPS, FISMP; AdventHealth, Altamonte Springs, FL
Phil Ayers, BS, PharmD, BCNSP, FMSHP, FASHP; Chief, Clinical Pharmacy Services, Mississippi Baptist Medical Center, Jackson, MS
Joel Daniel, PharmD, MS, CPPS; CoxHealth, Springfield, MO
Callee Brooks, PharmD candidate; The University of Tennessee Health Science Center, Methodist Le Bonheur Healthcare, Memphis, TN
Rachel Di Paolantonio, PharmD; Weis Markets Pharmacy, Schnecksville, PA
Joseph Boullata, PharmD, RPh, CNS-S, FASPEN, FACN; Clinical Nutrition - Pharmacy Specialist, Hospital of the University of Pennsylvania, Philadelphia, PA
Heather Ellis, PharmD; AdventHealth, Orlando, FL
Samantha Burton, PharmD, FISMP; Medication Safety Pharmacist - Smart Pumps, Cleveland Clinic Foundation, Cleveland, OH
Megan Fletcher, PharmD; Corewell Health, Grand Rapids, MI
Joel Daniel, PharmD, MS, CPPS; System Medication Safety Pharmacist, CoxHealth, Springfield, MO
Mona Hammam, PharmD, MS, BCPS, FISMP; Dana Farber Cancer Institute, Boston, MA
Morgan Greutman, PharmD, BCPS; Medication Safety Officer, Choctaw Nation Health Services Authority, Talihina, OK
Jacqueline Hartford, PharmD, BCPS, BCCCP, CPPS; LifeBridge Health, Baltimore, MD
Cassandra Hickman, PharmD; EHR Pharmacy Analyst, University of Kentucky HealthCare, Lexington, KY
Michael Hayes, PharmD, MBA; Cone Health, Greensboro, NC
G. Morgan Jones, PharmD, BCCCP, FCCM; Clinical Pharmacy Specialist - Neurocritical Care, Methodist Le Bonheur Healthcare, Memphis, TN
Emily Howes, CPhT-Adv, AAS; Cone Health, Greensboro, NC
Sarah Kim, PharmD, BCOP; Senior Protocol Content Administrator, City of Hope Hospital & Healthcare, Duarte, CA
Shannon Manzi, PharmD, BCPPS, FPPA; Boston Children’s Hospital, Boston, MA
Vivian Loo, PharmD, BCOP; Senior Protocol Content Administrator, City of Hope Hospital & Healthcare, Duarte, CA
Steve Mogridge, PA-C; Corewell Health, Grand Rapids, MI
Magdalene (Maggie) Mastalerz, PharmD; PGY2 HSPAL Resident, University of Kentucky HealthCare, Lexington, KY
Mary Nelson, MSN, RN; HonorHealth, Paradise Valley, AZ
Andrew Mays, PharmD, BCNSP, CNSC; Clinical Pharmacy Specialist, University of Mississippi Medical Center, Jackson, MS
Austin Price, PharmD, MBA, MS; Cone Health, Greensboro, NC
Casey Moore, PharmD; Medication Safety Pharmacist - Enterprise Pediatrics, Cleveland Clinic, Cleveland, OH
Anna Rikard, PharmD, BCGP, CPEL; Methodist Le Bonheur Healthcare, Memphis, TN
Jill Paslier, PharmD, CSP, FISMP; Paslier Consulting, LLC, Philadelphia, PA
Gretchen Roeger, PharmD, BCPS; OhioHealth, Columbus, OH
Amy Potts, PharmD, MMHC, BCPPS, FPPA; Program Director, Quality, Safety & Education, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
Dan Sheridan, MS, RPh, CPPS; OhioHealth Marion General Hospital & Hardin Memorial Hospital, Marion, OH
Kathryn Ruf, PharmD, MBA; Associate Director, Pharmacy Value and Analytics, University of Kentucky HealthCare, Lexington, KY
Winnie Stockton, PharmD, BCPPS; Children’s Hospital of Orange County, Orange, CA
Donald Singh, PharmD, MBA, BCPS; PGY2 Resident, Johns Hopkins Hospital & Healthcare, Baltimore, MD
Todd Walroth, PharmD, BCPS, BCCCP, FCCM; Eskanazi Health, Indianapolis, IN
Joseph Vu, PharmD; PGY2 Resident, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
Shane Wehler; Corewell Health, Grand Rapids, MI
Nicola Wake, BPharm, MRPharmS; Specialist Pharmacist: Lead Medication Safety, NHS Specialist Pharmacy Service, Medication Safety Officer, Northumbria
Jennifer
Healthcare Williams,
NHS Foundation Trust,PharmD,
NewcastleBCPS; Mercy
Upon Tyne, UK Medical Center, Cedar Rapids, IA

Mark Wolf Jr., PharmD; PGY2 Medication-Use Safety & Policy Pharmacy Resident, Univerity of Kentucky HealthCare, Lexington, KY
ISMP List of High-Alert Medications
in 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 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 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; employing
clinical decision support and automated alerts; and using 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 Medications Specific Medications

adrenergic agonists, IV (e.g., EPINEPHrine, phenylephrine, norepinephrine) EPINEPHrine, IM, and subcutaneous
adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol) epoprostenol (e.g., Flolan), IV
anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine) insulin U-500 (special emphasis*)
antiarrhythmics, IV (e.g., lidocaine, amiodarone) magnesium sulfate injection
antithrombotic agents, including: methotrexate, oral, nononcologic use
— anticoagulants (e.g., warfarin, low molecular weight heparin, unfractionated heparin) nitroprusside sodium for injection
— direct oral anticoagulants and factor Xa inhibitors (e.g., rivaroxaban, fondaparinux)
opium tincture
— direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran)
— glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide) oxytocin, IV
— thrombolytics (e.g., alteplase, reteplase, tenecteplase) potassium chloride for injection concentrate
cardioplegic solutions potassium phosphates injection
chemotherapeutic agents, parenteral and oral promethazine injection
dextrose, hypertonic, 20% or greater tranexamic acid injection
dialysis solutions, peritoneal and hemodialysis vasopressin, IV and intraosseous
epidural and intrathecal medications * All

forms of insulin, subcutaneous and IV, are
considered a class of high-alert medications.
inotropic medications, IV (e.g., digoxin, milrinone)
Insulin U-500 has been singled out for special
insulin, subcutaneous and IV emphasis to bring attention to the need for
distinct strategies to prevent the types of errors
liposomal forms of drugs (e.g., liposomal amphotericin B) and conventional counterparts (e.g., amphotericin that occur with this concentrated form of insulin.
B deoxycholate)
Background
moderate and minimal sedation agents, oral, for children (e.g., chloral hydrate, midazolam, ketamine)
Based on error reports submitted to the ISMP
moderate sedation agents, IV (e.g., dexmedeTOMIDine, midazolam, LORazepam)
National Medication Errors Reporting
neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium) Program (ISMP MERP), reports of harmful
opioids, all routes of administration (e.g., oral, sublingual, parenteral, transdermal) errors in the literature, studies that identify the
drugs most often involved in harmful errors,
parenteral nutrition preparations and input from practitioners and safety experts,
sodium chloride for injection, hypertonic, greater than 0.9% concentration ISMP created and periodically updates a list
of potential high-alert medications. During
sterile water for injection, inhalation and irrigation (excluding pour bottles) in containers of 100 mL or more
September and October 2023, practitioners
sulfonylurea hypoglycemics, oral (e.g., glimepiride, glipiZIDE, glyBURIDE, TOLBUTamide) responded to an ISMP survey designed
to identify which medications were most
Abbreviation definitions: IV—intravenous, IM—intramuscular frequently considered high-alert medications.
Further, to ensure relevance and completeness,
© ISMP 2024. Permission is granted to healthcare provider organizations to reproduce and distribute portions of the material contained
herein, for internal non-commercial purposes, but only with proper attribution made to ISMP. All other use of the material is prohibited
the clinical staff at ISMP and members of the
without prior written permission from ISMP. ISMP advisory board were asked to review
Report medication errors to the ISMP National Medication Errors Reporting Program (ISMP MERP) at: www.ismp.org/MERP.
the potential list. This list of medications and
medication categories reflects the collective
thinking of all who provided input.

www.ismp.org
©2024 ISMP. All Rights Reserved. MS5760