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.

Use ISMP's List of High-Alert Medications in Acute Care Settings to determine which medications in your organization require special safeguards to reduce the risk of errors and minimize harm. Strategies may include:

  • Standardizing the ordering, storage, preparation, and administration of these medications
  • Improving access to information about these drugs
  • Limiting access to high-alert medications
  • Using auxiliary labels and automated alerts
  • Employing redundancies
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 greate
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-released 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)*  (All forms of insulin, subcutaneous and IV, are considered a class of 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.)
magnesium sulfate injection
methotrexate, oral, non-oncologic use
opium tincture
oxytocin, IV
nitroprusside sodium for injection
potassium chloride for injection concentrate
potassium phosphates injection
promethazine, IV
vasopressin, IV or intraosseous

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This list includes look-alike and sound-alike name pairs. Use this list to determine which medications require special safeguards to reduce the risk of errors and minimize harm.