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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 like improving access to information about 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 employing redundancies such as automated or independent doublechecks 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
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, apixaban, rivaroxaban)
  • direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran etexilate)
  • 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)


  • 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 Medications
EPINEPHrine, subcutaneous
epoprostenol (Flolan), IV
insulin U-500 (special emphasis)*
magnesium sulfate injection
methotrexate, oral, nononcologic use
opium tincture
oxytocin, IV
nitroprusside sodium for injection
potassium chloride for injection concentrate
potassium phosphates injection
promethazine, IV
vasopressin, IV or intraosseous

*All forms of insulin, subcutaneous and IV, are considered a class of high-alert medications. Insulin U500 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 ISMP National Medication Errors Reporting Program, reports of harmful errors in the literature, studies that identify the drugs most often involved in harmful errors, and input from practitioners and safety experts, ISMP created and periodically updates a list of potential highalert medications. During May and June 2014, practitioners responded to an ISMP survey designed to identify which medications were most frequently considered highalert drugs by individuals and organizations. Further, to assure relevance and completeness, the clinical staff at ISMP, members of the ISMP 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.

© ISMP 2014. Permission is granted to reproduce material with proper attribution for internal use within healthcare organizations. Other reproduction is prohibited without written permission from ISMP. Report actual and potential medication errors to the ISMP National Medication Errors Reporting Program (ISMP MERP) via the website ( or by calling 1800FAILSAF(E).


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