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.

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