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High-Alert Medication List for Acute Care Settings Updated for 2024

High-alert medications are an essential component of drug therapy. However, while errors with these products are not necessarily more common, the consequences are often quite harmful and can even be fatal. To reaffirm and identify possible additions or deletions to our high-alert medication list, we recently reviewed reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP), clinical and safety literature, and input that we received from US medication safety experts. In addition, between September and October 2023, ISMP conducted a survey on high-alert medications in acute care settings.

The first list of high-alert medications was published in 1989 (Davis NM, Cohen MR. Today’s poisons: how to keep them from killing your patients. Nursing. 1989;19[1]:49-51). That initial list included six medications that are still on ISMP’s list today—intravenous (IV) lidocaine, vinCRIStine, sodium chloride for injection greater than 0.9%, morphine injection, insulin, and potassium chloride for injection concentrate. In this newsletter, we report the results of our recent survey and compare them to a survey we conducted in 2018. We will also discuss changes we made to the list. The updated ISMP List of High-Alert Medications in Acute Care Settings be found on our website

2023 Findings

Respondent profile. ISMP extends our thanks to nearly 100 practitioners who validated our ISMP List of High-Alert Medications in Acute Care Settings. Most practitioners were pharmacists (85%) working in an inpatient pharmacy (63%), although we also heard from others (e.g., nurses, risk/quality/safety managers, pharmacy technicians). 

Drugs considered high-alert medications. Table 1 shows the drugs on the 2018 ISMP List of High-Alert Medications in Acute Care Settings, and the percent of respondents who considered these to be high-alert medications in 2018 and 2023. Half or more of the 2023 respondents thought that all of the drugs on our list were high-alert medications except IV adrenergic antagonists (49%) as well as oral sulfonylurea hypoglycemics (39%), which was up from 29% in our 2018 survey. 

In 2023, more than 80% of respondents thought these medication classes or specific drugs were high-alert medications: 

  • U-500 insulin (100%)

  • potassium chloride for injection concentrate (100%)

  • epidural and intrathecal medications (100%) 

  • sodium chloride for injection, greater than 0.9% (100%)

  • chemotherapeutic agents, parenteral and oral (98%)

  • insulin, subcutaneous and IV (98%)

  • neuromuscular blocking agents (98%)

  • antithrombotic agents (96%)

  • potassium phosphates injection (93%) 

  • methotrexate, oral, nononcologic use (93%) 

  • epoprostenol (e.g., Flolan), IV (90%) 

  • opioids, all routes of administration (e.g., oral, sublingual, parenteral, transdermal) (88%)

  • parenteral nutrition preparations (82%) 

Possible additions and changes. ISMP asked for feedback about one possible addition, tranexamic acid injection, to the ISMP list, upon which about half (49%) of respondents agreed that it should be added to the list. 

Comparison between 2023 and 2018 

Differences between 2023 and 2018 findings. Prior to 2023, ISMP last conducted a survey on high-alert medications in acute care settings in 2018 (Table 1), after which we updated our list based in part on the survey results. 

Compared to 2018, the drugs listed below had the largest increase in the percentage of respondents who consider them high-alert medications. 

  • sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers of 100 mL or more (52% thought this was a high-alert medication in 2018, 77% in 2023)

  • potassium phosphates injection (72% in 2018, 93% in 2023) 

  • epoprostenol (e.g., Flolan), IV (70% in 2018, 90% in 2023) 

  • methotrexate, oral, nononcologic use (74% in 2018, 93% in 2023)                   

  • oxytocin, IV (60% in 2018, 79% in 2023) 

  • EPINEPHrine, IM, and subcutaneous (51% in 2018, 68% in 2023) 

2023 Change to the ISMP List 

Based on practitioner feedback, review of the literature and error reports, and input from our clinical advisory board, ISMP has made the following change to its current ISMP List of High-Alert Medications in Acute Care Settings:

  • Tranexamic acid injection was added to our list under “specific medications.” Tranexamic acid is an antifibrinolytic agent that is used in a variety of hemorrhagic conditions to control bleeding, including postpartum hemorrhage. It works by preventing the breakdown of fibrin, thus promoting clotting. Respondents shared that errors are often related to storage issues and mix-ups with look-alike medication vials, most often anesthetics that are also commonly stored in surgical and procedural locations. When accidentally administered via a neuraxial route, tranexamic acid injection is a potent neurotoxin with a mortality rate of about 50% and is almost always harmful to the patient. Survivors of neuraxial tranexamic acid often experience seizures, permanent neurological injury, and paraplegia. ISMP has repeatedly warned against errors with tranexamic acid, including a feature article in the May 23, 2019, ISMP Medication Safety Alert!, and most recently a Worth repeating in the August 24, 2023 newsletter. ISMP also published a National Alert Network (NAN) warning on September 9, 2020. 

We also received suggestions to consider adding about a dozen other medications to our list, including investigational medications, any controlled drugs, IV immunosuppressive agents, hypotonic sodium chloride, naloxone, alprostadil, and tolvaptan. Of note, about half of the suggested additions were already on our list (e.g., bivalirudin, heparin, alteplase, tenecteplase, intrathecal medications). We greatly appreciate the suggestions that readers made for additions to the ISMP list of high-alert drugs. Although other changes were not made at this time, we will continue to monitor the suggested items and consider them for further assessment in our next survey. 

Table 1. Comparison of respondents who believe these drugs/categories are high-alert medications, 2023 and 2018

Table 1. Comparison of respondents who believe these drugs/categories are high-alert medications, 2023 and 2018

*2023 survey specified IV only

†2023 expanded to include minimal sedation agents

‡2023 changed oral hypoglycemics to oral sulfonylurea hypoglycemics


Again, ISMP thanks all who took the time to provide us with feedback about additions or deletions to our high-alert medication list. Our updated list can be found on our website. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors in your organization. Safeguards may include strategies such as limiting access to high-alert medications; employing clinical decision support and automated alerts; standardizing the ordering, storage, preparation, and administration of these products; using redundancies such as automated or independent double checks when necessary; using auxiliary labels; and improving access to information about these drugs. 


Suggested citation:

Institute for Safe Medication Practices (ISMP). High-alert medication list for acute care settings updated for 2024. ISMP Medication Safety Alert! Acute Care. 2024;29(1):1-4.