Institute for Safe Medication Practices

ISMP’s List of High-Alert 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
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
drugs, the consequences of an error are clearly more devastating to employing redundancies such as automated or independent double-
patients. We hope you will use this list to determine which medica- checks when necessary. (Note: manual independent double-checks
tions require special safeguards to reduce the risk of errors. This are not always the optimal error-reduction strategy and may not be
may include strategies like improving access to information about practical for all of the medications on the list).

Classes/Categories of Medications Specific Medications

adrenergic agonists, IV (e.g., epinephrine, phenylephrine, norepinephrine) colchicine injection

adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol) epoprostenol (Flolan), IV

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

antiarrhythmics, IV (e.g., lidocaine, amiodarone) magnesium sulfate injection

antithrombotic agents (anticoagulants), including warfarin, low-molecular-weight methotrexate, oral, non-oncologic use
heparin, IV unfractionated heparin, Factor Xa inhibitors (fondaparinux), direct
thrombin inhibitors (e.g., argatroban, lepirudin, bivalirudin), thrombolytics (e.g., oxytocin, IV
alteplase, reteplase, tenecteplase), and glycoprotein IIb/IIIa inhibitors (e.g., eptifi-
batide) nitroprusside sodium for injection

cardioplegic solutions potassium chloride for injection concentrate

chemotherapeutic agents, parenteral and oral potassium phosphates injection

dextrose, hypertonic, 20% or greater promethazine, IV

dialysis solutions, peritoneal and hemodialysis sodium chloride for injection, hypertonic (greater than 0.9% concentration)

epidural or intrathecal medications sterile water for injection, inhalation, and irrigation
(excluding pour bottles) in containers of 100 mL or more
hypoglycemics, oral

inotropic medications, IV (e.g., digoxin, milrinone) Background

liposomal forms of drugs (e.g., liposomal amphotericin B)

moderate sedation agents, IV (e.g., midazolam) Based on error reports submitted to the USP-ISMP Medication Errors Reporting
Program, reports of harmful errors in the literature, and input from practitioners and
moderate sedation agents, oral, for children (e.g., chloral hydrate) safety experts, ISMP created and periodically updates a list of potential high-alert
medications. During February-April 2007, 770 practitioners responded to an ISMP
narcotics/opiates, IV, transdermal, and oral (including liquid concentrates, immediate
survey designed to identify which of these medications were most frequently consid-
and sustained-release formulations)
ered high-alert drugs by individuals and organizations. Further, to assure relevance
neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium) 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
© ISMP 2007

radiocontrast agents, IV drugs and drug categories reflects the collective thinking of all who provided input.
total parenteral nutrition solutions

© ISMP 2007. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other
reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Institute for Safe
Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at [Link] or by calling Medication Practices
1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters’ wishes as to the level of detail [Link]
included in publications.