High Alert Medications in Acute Care Settings

High Alert medications are drugs that bear a heightened risk of causing significant client
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 clients.
These medications require special safeguards to reduce the risk of errors. This may
include strategies such as 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; and
employing redundancies such as automated or independent double-checks when
necessary (Institute of Safe Medication Practices, 2014).

Independent double Check: Another licensed nurse will perform a second check to
identify the medication, dose, and route to be administered.

Joint Commission Top 5 High Alert Medications – MUST KNOW!

• Insulin – subcutaneous and IV

• Opiates and Narcotics – IV, transdermal, oral
• Injectable Potassium Chloride or Phosphate Concentrate
• Intravenous Anticoagulants (Heparin)
• Sodium Chloride Solutions above 0.9 percent concentration (Joint
Commission, 1999).

DOUBLE CHECK these Medications with a 2nd Licensed Nurse!

Common Medications for the Brand-New Nurse

Medication Class/Category Route Medication Example Specific Medications
Adrenergic Agonists IV Epinephrine Epinephrine, SubQ
Phenylephrine
Norepinephrine
Adrenergic antagonists IV Propranolol
Metoprolol
Labetalol
Anticoagulants PO Warfarin
IV Heparin
SQ Low molecular wt heparin
Factor Xa inhibitors IV Fondaparinux
Apixaban
Rivaroxaban
Medication Class/Category Route Medication Example Specific Medications
Direct Thrombin Inhibitors IV Argatroban
Bivalirudin
Dabigatran etexilate
Thrombolytics IV Alteplase
Reteplase
Tenecteplase

Glycoprotein IIb/IIIa Inhibitors IV Eptifibatide

Sterile water IV In containers of 100 mL or
Inhalation more
Irrigation
Dextrose, hypertonic IV 20% or greater
Dialysis Solutions Peritoneal
Hemodialysis
Hypoglycemics PO
Inotropics IV Digoxin
Milrinone
Insulin SQ ALL forms of insulin Insulin U-500 (special
IV emphasis)**
Liposomal medications IV Liposomal Amphotericin B
Amphotericin B
desoxycholate
Moderate sedation agents, PO Chloral hydrate
for children
Potent Vasodilator IV Epoprostenol
Nitroprusside sodium
Electrolyte IV Magnesium sulfate
Anti-Rheumatic PO Methotrexate Methotrexate
(non-oncologic use)
Oxytocic Agent IV Oxytocin
Phenothiazines IV Promethazine
Anti-Diuretic hormone IV Vasopressin
Chemotherapeutic agents PO
IV
**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.

References
Joint Commission (1999). Sentinel Event Alert.
Retrieved from https://www.jointcommission.org/assets/1/18/SEA_11.pdf

Institute of safe medication practices (2014). Retrieved from www.ismp.org