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ISMP List of High-Alert Medications in
Community/Ambulatory Healthcare

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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. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors and minimize harm. This may include strategies like providing mandatory patient education; improving access to information about these drugs; using auxiliary labels and automated alerts; employing automated or independent double checks when necessary; and standardizing the prescribing, storage, dispensing, and administration of these products.

Classes/Categories of Medications
antiretroviral agents (e.g., efavirenz, lamiVUDine, raltegravir, ritonavir, combination antiretroviral products)
chemotherapeutic agents, oral (excluding hormonal agents) (e.g., cyclophosphamide, mercaptopurine, temozolomide)
hypoglycemic agents, oral
immunosuppressant agents (e.g., azaTHIOprine,
cycloSPORINE, tacrolimus)
insulin, all formulations
opioids, all formulations
pediatric liquid medications that require measurement
pregnancy category X drugs (e.g., bosentan, ISOtretinoin)


Specific Medications
chloral hydrate liquid, for sedation of children
heparin, including unfractionated and low molecular weight heparin
methotrexate, non-oncologic use
midazolam liquid, for sedation of children


Based on error reports submitted to the ISMP Medication Errors Reporting Program (ISMP MERP), reports of harmful errors in the literature, and input from practitioners and safety experts, ISMP created a list of potential highalert medications. During June-August 2006, 463 practitioners responded to an ISMP survey designed to identify which medications were most frequently considered highalert drugs by individuals and organizations. In 2008, the preliminary list and survey data as well as data about preventable adverse drug events from the ISMP MERP, the Pennsylvania Patient Safety Reporting System, the FDA MedWatch database, databases from participating pharmacies, public litigation data, literature review, and a small focus group of ambulatory care pharmacists and medication safety experts were evaluated as part of a research study funded by an Agency for Healthcare Research and Quality (AHRQ) grant. This list of drugs and drug categories reflects the collective thinking of all who provided input. This list was created as part of the AHRQ funded project “Using risk models to identify and prioritize outpatient highalert medications” (Grant # 1P20HS01710701).


Copyright 2011 Institute for Safe Medication Practices (ISMP). This document may be freely redistributed without charge in its entirety provided that this copyright notice is not removed. It may not be sold or distributed for a charge or for profit or used in commercial documents without the written permission of ISMP. Any quotes or references to this document must be properly cited. This document is provided “as is” without any express or implied warranty. This document is for educational purposes only and does not constitute legal advice. If you require legal advice, you should consult with an attorney.

Posted on January 30, 2011

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