High-Alert Medications—Heparin, Concentrated Electrolytes, and Magnesium: Practical Strategies in Pursuit of Safety


Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Numerous organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions against serious patient harm.  

Join the ISMP faculty as we focus particular attention on the potential safe use risks with heparin, concentrated electrolytes, and magnesium using the results from ISMP Medication Safety Self Assessment® for High-Alert Medications. Faculty will review specific safety characteristics of each these important drug classes, describe self-assessment findings related to the use of these medications, and discuss the necessary practice strategies for harm prevention when using these high-alert medications. 

Intended Audience:

  • Pharmacists, Physicians, Nurses, PAs, CRNAs

  • Medication Safety Officers

  • Quality Professionals

  • Risk Managers

  • Leaders in Pharmacy and Nursing

  • Pharmacy and Anesthesia Technicians

Learning Objectives: 

Following completion of this activity, participants will be able to:

  1. Discuss the characteristics of high-alert medications and their impact on patient safety.

  2. Describe the low scoring assessment items for heparin, concentrated electrolytes, and magnesium from the ISMP Medication Safety Self Assessment® for High-Alert Medications.

  3. Cite at least two effective strategies each for heparin, concentrated electrolytes, and magnesium. 


Michelle Mandrack, MSN, RN, Director of Consulting Services, ISMP

Christina Michalek, BSc Pharm, RPh, FASHP, Medication Safety Specialist, ISMP

Susan Paparella, MSN, RN, Vice President, ISMP



This activity is funded by Baxter. 

CE Accreditation

Pharmacists and Pharmacy Technicians

Release Date: January 25, 2022
Expiration Date: January 25, 2024

This CE activity is jointly provided by ProCE, LLC and the Institute for Safe Medication Practices (ISMP). ProCE is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity Number 0221-9999-22-002-H05-P/T has been assigned to this knowledge-based home-study CE activity. This activity is approved for 1.25 contact hour (0.125 CEU) in states that recognize ACPE providers. This CE activity is provided at no cost to participants. Statements of completion will be issued online at www.ProCE.com upon completion of the evaluation and post-test with a score of 70% or higher. Proof of completion will be posted in NABP CPE Monitor profiles. No partial credit will be given.

This activity has been approved for up to 1.25 California State Nursing contact hours by the provider, Debora Simmons, who is approved by the California Board of Registered Nursing, Provider Number CEP 13677. Credit will only be issued to individuals that are individually registered and attend the entire program.

This meeting has been approved for a total of 1.0 contact hours of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.  CPHRM Content Outline Category 1 Clinical/Patient Safety.


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