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


How to cite: Institute for Safe Medication Practices (ISMP). ISMP List of High-Alert Medications in Acute Care Settings. ISMP; 2018.

Classes/Categories of Medications     (Abbreviation definitions: IV—intravenous, IM—intramuscular)
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, unfractionated heparin)
- direct oral anticoagulants and factor Xa inhibitors (e.g., dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, fondaparinux)
- direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran)
- glycoprotein IIb/IIIa inhibitors (e.g.,eptifibatide)
- thrombolytics (e.g.,alteplase, reteplase, tenecteplase)
cardioplegic solutions
chemotherapeutic agents, parenteral and oral
dextrose, hypertonic, 20% or greater
dialysis solutions, peritoneal and hemodialysis
epidural and intrathecal medications
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, LORazepam)
moderate and minimal sedation agents, oral, for children (e.g., chloral hydrate, midazolam, ketamine [using the parenteral form])
opioids, including:
- IV
- oral (including liquid concentrates, immediate- and sustained-released formulations)
- transdermal 
neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)
parenteral nutrition preparations
sodium chloride for injection, hypertonic, greater than 0.9% concentration
sterile water for injection, inhalation and irrigation (excluding pour bottles) in containers of 100 mL or more
sulfonylurea hypoglycemics, oral (e.g., chlorproPAMIDE, glimepiride, glyBURIDE, glipiZIDE, TOLBUTamide)
Specific Medications
EPINEPHrine, IM, subcutaneous
epoprostenol (e.g., 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, nononcologic use
nitroprusside sodium for injection
opium tincture
oxytocin, IV
potassium chloride for injection concentrate
potassium phosphates injection
promethazine injection
vasopressin, IV and intraosseous

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