High alert

medications
By Athirah
Definition

compared to other medications

About 15 years ago, the

Institute for Safe Medication
Prctices (ISMP) in the United
States has conducted a research
to determine the medications and
conditions

which

was

most

tendency to harm patients. The

study gathered the results of data
submitted by an approximate of
161 health care organisation on
serious errors that had taken
place during this period. The
outcomes of the study showed
that a majority of the medication
errors resulting in death or
serious injury involved a small

they cause harm more commonly

and the harm they yielded are
likely to be more severe. The
harm leads not only to patient
suffering but also to increment of
costs associated with the care of
these patients. The consequences
associated

can

be

especially

serious and studies suggest this

applies across the board2. In a
study done by Budnitz D.S., et al.,

(54.9%) occurred with central

nervous system, antineoplastic
and

cardiovascular

drug

products5. The top five drugs

cited for overall incident records,
medication

errors

reaching

patinets without causing harm, or

errors resulting in patient harm,
were high alert medications such
as insulin, morphine, heparin,
potassium

chloride

and

warfarin6.

insulin, warfarin and digoxin

were implicated in one of every

HAM Categories

three estimated ADEs treated for

the

elderly,

department3.

in
Edgar

The

emergency
et

al.

American

Pharmaceutical Association has

reviewed medical event reports

listed

in a US national database and

cardiovascular

drugs,

reported that heparin, xylocaine,

chemotherapeutic

drugs,

adrenaline

potassium

narcotics, opiates, anticoagulants,

chloride were the drugs most

benzodiazepines, neuromuscular

commonly involved in critical

blocking agents and electrolytes5.

incidents4.

al.

The ISMP has 19 categories and

Medications

examined 469 fatal medication

13 specific medications in its list

are medications which are more

error reports and indicated that

of HAM (Table 1).

likely to be associated with harm

the largest number of deaths

number of specific medications.

The ISMP has termed these
medications that have the highest
risk of causing injury when
misused

as

Medications or

High-Alert

HAM1.

High-Alert

and

Phillips

et

eight

HAM

categories:

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Table 1. List of Classes of Medications categorised under High Alert Medications
Common Risk Factors

Strategies in Preventing Errors Involving

The common risk factors for

errors associated with High-Alert

Procurement

1. Limit the drugs strengths available In health

center formulary.

Medications include poorly written

medication orders and incorrect

2. Avoid frequent changes of brand. Notify the end

dilution

user whenever there are changes.

procedures.

Confusion

between IM, IV, Intrathecal, Epidural

preparations and confusion between
different strengths of the same
medications such as sodium chloride

Storage

1. All HAM should be kept in individual labelled

containers. Whenever possible avoid look-alike
and sound-alike drugs or different strengths of the
same drug from being stored side by side.

3% and sodium chloride 0.9% may

predispose errors in handing HAM.

2.

Ambiguous

differences In medication names (e.g DOPamine

labeling

on

concentration and total volume of

medications also increases the risk
for errors in prescribing drugs listed

Use TALL-man lettering to emphasize

and DOBUtamine).
3. Label all containers used for storing HAM in red
as "HIGH ALERT".

as HAM, apart from look alike or

sound alike product or similar
packaging2.
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Ordering

1.

Use standardized forms for cytotoxic drugs and

parenteral nutritions.
2. Do not use abbreviations when prescribing HAM.
3. Specify the strength of dilution and rate of infusion for
HAM prescribed. (e.g. Noradrenaline 4mg in 50ml NS,
run at 5ml/hr)
Rerences:
4. Do not use trailing zero when prescribing. (e.g. 5.0mg
can be mistaken as 50mg)
Preparation

1. Establish a counterchecking system for all

preparations involving HAM.

References:
1.

Institue

for

Safe

Medication

Practices (ISMP): Part IIHow to

pre- vent errorsSafety issues

1. All HAM containers issued to wards/units must be

Dispensing/
Supply
labeled as "HIGH ALERT".

with patient-controlled analgesia.

ISMP

Medication

Acute

2. All HAM must be counter-checked before dispensing.

Care,

Safety

Jul.

24,

Alert:
2003.

http://www.ismp.org/
newsletters/acutecare/articles/20
030724.asp?ptr=y (last accessed
Jul 2011).
2.

McCannon C.J., Hackbarth A.D.,

Giffin

F.A.:

Miles

to

go:

An

introduction to the 5 Million Lives

Campaign. Jt Comm J Qual Patient
Saf 33:477484, Aug. 2007.
3.

Leape L.L., et al.: The nature of

adverse events in

hospitalized

patients. Results of the Harvard

Medical Practice Study II. N Engl J
Med 324:377384, Feb. 7, 1999.
4.

Leape L.L., et al.: The nature of

adverse events in

Conclusion

hospitalized

patients. Results of the Harvard

Medical Practice Study II. N Engl J

As the conclusion, High-Alert Medications posses high risk for

errors and the impact on patients safety is a system problem, which

Med 324:377384, Feb. 7, 1991.

5.

T.:

improve

will therefore require a joint effort from all health care participants
including doctors, pharmacists and nurses to improve patients safety

Nolan

System
patient

changes
safety.

to
BMJ

320:771773, Mar. 18, 2000.

6.

Rozich J.D., et al.: Standardization

with respect to minimising the errors and ultimately, their

as a mechanism to improve safety

consequences.

in health care. Jt Comm J Qual

Patient Saf 30:514, Jan. 2004.

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