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 (e.g., wrong drug, wrong dose, wrong route, wrong resident). Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients or residents.

Use ISMP's List of High-Alert Medications in Long-Term Care (LTC) Settings to determine which medications require special safeguards to reduce the risk of errors. 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 such as automated or independent double checks 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) 

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. Facilities are also encouraged to use other resources, such as the Beers Criteria1,2 and STOPP and START Criteria3 to identify and address medications that should be avoided in the elderly population, which are different from high-alert medications.

How to cite: Institute for Safe Medication Practices (ISMP). ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.  ISMP; 2021.

Classes/Categories of Medications

Anti-Parkinson's drugs, including carbidopa, levodopa, and combination products that contain at least one of these ingredients

Antithrombotic agents, parenteral and oral, including:

  • anticoagulants (e.g., warfarin, low molecular weight heparin, unfractionated heparin)

  • direct oral anticoagulants (e.g., dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban)

  • direct thrombin inhibitors (e.g., dabigatran)

Chemotherapeutic agents

  • Oral and parenteral chemotherapy (e.g., capecitabine, cyclophosphamide)

  • Oral targeted therapy and immunotherapy (e.g., palbociclib [IBRANCE], imatinib [GLEEVEC], bosutinib [BOSULIF])

  • Excludes hormonal therapy 

GABA analogs (e.g., gabapentin, pregabalin) used to treat neuropathic pain

Immunosuppressants, oral and parenteral (e.g., azaTHIOprine, cycloSPORINE, cyclophosphamide, tacrolimus, abatacept [ORENCIA], adalimumab [HUMIRA])

Insulins, all formulations and strengths (e.g., U-100, U-200, U-300, U-500)

Opioids, all routes of administration (e.g., oral, sublingual, parenteral, transdermal), including liquid concentrates, immediate- and sustained-release formulations, and combination products with another drug

Parenteral nutrition preparations

Sulfonylurea hypoglycemics, oral (e.g., chlorproPAMIDE, glimepiride, glyBURIDE, glipiZIDE, TOLBUTamide)

Specific Medications

Concentrated morphine solution (20 mg/mL), oral (special emphasis)*

Digoxin, parenteral and oral

EPINEPHrine, IM, subcutaneous

Insulin U-500

Iron dextran, parenteral

Methotrexate, oral and parenteral, nononcologic use (special emphasis)*


Sacubitril and valsartan (ENTRESTO)

*All routes of opioids, all parenteral and oral chemotherapy, and all subcutaneous and IV insulin are considered high-alert medications. These specific medications have been singled out for special emphasis to bring attention to the need for distinct strategies to prevent the types of errors that occur with these medications.


Based on error reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP), reports of harmful errors in the literature, and input from practitioners and safety experts, ISMP created and has periodically updated a list of high-alert medications in the long-term care (LTC) setting. The original list was developed in 2016, which included input from practitioners from LTC facilities who responded to an ISMP survey on the topic. To update the list and assure its relevance and completeness, the clinical staff at ISMP, members of ISMP's LTC Advisory Board, and safety experts throughout the US were asked to review the list and potential additions. This current list of specific medications and medication classes/categories reflects the collective thinking of all who provided input.


  1. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;00(0):1-21. doi:10.1111/jgs.15767
  2. Institute for Safe Medication Practices (ISMP). Updated 2019 American Geriatrics Society (AGS) Beers Criteria released along with key principles to optimize their use. ISMP Medication Safety Alert! Long-Term Care AdviseERR. 2019;7(2):1-3.
  3. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-8.

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