High-Alert Medications

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. This list may be used 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 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).

EPINEPHrine, IM, SC Oxytocin, IV
Epoprostenol (Flolan), IV Nitroprusside sodium for injection
Insulin U-500 (special emphasis*) Potassium chloride for injection concentrate
Magnesium sulfate injection Potassium phosphates injection
Methotrexate, oral, non-oncologic use Promethazine injection
Opium tincture Vasopressin, IV or intraosseous
Adrenergic agonists, IV (eg, EPINEPHrine, phenylephrine, norepinephrine)
Adrenergic antagonists, IV (eg, propranolol, metoprolol, labetalol)
Anesthetic agents, general, inhaled and IV (eg, propofol, ketamine)
Antiarrhythmics, IV (eg, lidocaine, amiodarone)

Antithrombotic agents, including:

• Anticoagulants (eg, warfarin, low-molecular-weight heparin, unfractionated heparin)

• Direct oral anticoagulants and Factor Xa inhibitors (eg, dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, fondaparinux)

• Direct thrombin inhibitors (eg, argatroban, bivalirudin, dabigatran)

• Thrombolytics (eg, alteplase, reteplase, tenecteplase)

• Glycoprotein IIb/IIIa inhibitors (eg, eptifibatide)

Cardioplegic solutions
Chemotherapeutic agents, parenteral and oral
Dextrose, hypertonic (20% or greater)
Dialysis solutions, peritoneal and hemodialysis
Epidural or intrathecal medications
Inotropic medications, IV (eg, digoxin, milrinone)
Insulin, subcutaneous and IV
Liposomal forms of drugs (eg, liposomal amphotericin B) and conventional counterparts (eg, amphotericin B desoxycholate)
Moderate sedation agents, IV (eg, dexmedetomidine, midazolam, LORazepam)
Moderate and minimal sedation agents, oral, for children (eg, chloral hydrate, midazolam, ketamine [using IV form])
Narcotics/opioids, IV, transdermal, oral (including liquid concentrates, immediate and sustained-release forms)
Neuromuscular blocking agents (eg, succinylcholine, rocuronium, vecuronium)
Parenteral nutrition preparations
Sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers of 100mL or more
Sodium chloride for injection, hypertonic, greater than 0.9% concentration
Sulfonylurea hypoglycemics, oral (eg, chlorproPAMIDE, glimepiride, glyBURIDE, glipiZIDE, TOLBUTamide)

* All forms of insulin, SC and IV, are considered high-alert medications. Insulin U-500 has been singled out for special emphasis to bring attention to the need for distinct strategies to prevent the types of errors that occur with this concentrated form of insulin.

Based on error reports submitted to the Institute of Safe Medication Practices (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 June and July 2018, practitioners responded to an ISMP survey designed to identify which drugs were most frequently considered high-alert medications by individuals and organizations. Further, to assure relevance and completeness, the clinical staff at ISMP and members of the ISMP advisory board were asked to review the potential list. This list of medications and drug categories reflects the collective thinking of all who provided input.


Source: Institute for Safe Medication Practices. High-Alert Medications in Acute Care Settings. 2018.
Available at: https://www.ismp.org/recommendations/high-alert-medications-acute-list. Accessed August 24, 2022.

(Rev. 9/2022)