Recommendations

High-Alert Medications in Long-Term Care (LTC) 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 Long-Term Care (LTC) Settings to determine which medications in your facility require special safeguards to reduce the risk of errors and minimize harm. Strategies may include: 

  • Standardizing the ordering, storage, preparation, and administration of these products
  • Improving access to information about these drugs
  • Limiting access to high-alert medications
  • Using auxiliary labels and automated alerts
  • Employing redundancies 

Long-Term Acute Care (LTAC) facilities, and LTC facilities with subacute units or where a wide variety of intravenous medications are administered, should also use the ISMP List of High-Alert Medications in Acute Care Settings, which can be found in the related items. Facilities are also encouraged to use other resources, such as the Beers Criteria1 and STOPP and START Criteria,2 to identify and address medications that should be avoided in the elderly population, which are different from high-alert medications.

Classes/Categories of Medications
anticoagulants, parenteral and oral*
chemotherapeutic agents, parenteral and oral (excluding hormonal agents)
hypoglycemics, oral (including combination products with another drug)
insulins, all formulations and strengths (e.g., U-100, U-200, U-300, U-500)
parenteral nutrition preparations
opioids - parenteral, transdermal, and oral (including liquid concentrates, immediate- and sustained-release formulations, and combination products with another drug)
Specific Medications
digoxin, parenteral and oral
EPINEPHrine, parenteral
iron dextran, parenteral
methotrexate, oral, non-oncology use **
concentrated morphine solution, oral **

*including warfarin and newer agents

** All forms of chemotherapy are considered a class of high-alert medications. Oral methotrexate for non-oncology purposes has been singled out for special emphasis to bring attention to the need for distinct strategies to prevent wrong frequency errors that occur with this drug when used for non-oncology purposes that can result in death.

** All forms of opioids are considered a class of high-alert medications. Concentrated morphine solution has been singled out for special emphasis to bring attention to the need for distinct strategies to prevent wrong frequency errors that occur with this drug that can result in death.


References

  1. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227–46.
  2. PL Detail - Document, STARTing and STOPPing medications in the elderly. Pharmacist’s Letter/Prescriber's Lettr. September 2011.

More Recommendations

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.
This list includes medications that should not be crushed because of their special pharmaceutical formulations or characteristics, such as sustained release.