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High Alert Medications

TM High-alert (or high-hazard) medications are medications that are most likely to cause sig-

Nightingale nificant harm to the patient, even when used as intended. The Institute for Safe Medication
Practices (ISMP) reports that, although mistakes may not be more common in the use of these
Home Healthcare medications, when errors occur the impact on the patient can be significant.*

Analgesics: Opioids
Opioids are high alert medications because they have the potential of errors in Midazolam injection
calculation of dosages and concentrations, proper identification of look-alike, Midazolam injection is considered a high-alert
sound-alike medications, and their potential for causing respiratory depression. medication because of the risk of respiratory de-
pression and respiratory arrest when used without
Buprenorphine Buprenex®, Subutex®
appropriate resuscitative equipment or qualified
Butorphenol Stadol®
personnel for monitoring.
Codeine Codeine phosphate, codeine sulfate, Tylenol with
codeine® Midazolam injection Versed®
Hydrocodone Lorcet®, Lortab®, Norco®, Vicodin®, Zydone®
Hydromorphone Dilaudid® Injectable Cardiovascular Agents:
Levorphanol Levo-Dromoran®
Meperidine Demerol®, Meperitab®
These injectable antiarrythmics are high-alert medi-
Methadone Dolophine®, Methadone
cations because of the increased risk of bradycar-
Morphine sulfate Avinza®, Kadian®, MSIR®, MSContin®, Oramorph®,
dia and AV block during administration. Appropri-
ate monitoring is required.
Nalbuphine Nubain®
Oxycodone OxyContin®, OxyIR®, Roxicodone® Amiodarone Cordarone®, Pacerone®
Oxymorphone Numorphan®, Opana®, Opana ER® Ibutilide Corvert®
Paregoric camphorated tincture of opium Isoproterenol Isuprel®
Pentazocine Talwin®, Talwin NX® Procainamide Procanbid®
Propoxyphene Darvon®, Darvon N®, Darvocet® Quinidine Quinidine

Anticoagulants Injectable Cardiovascular Agents: Beta

Anticoagulants are high-alert because they have a narrow therapeutic range, Blockers
many food and drug interactions, and complex dosing regimens. Injectable beta-blockers are high-alert medica-
Argatroban Argatroban tions because of the increased risk of hypotension,
Bivalirudin Angiomax® bradycardia and AV block during administration.
Cilostazol Pletal® Appropriate monitoring is required. Also, some
Clopidogrel Plavix® significant differences exist between oral and IV
Dalteparin Fragmin® dosing. Caution must be taken when switching
Dipyridamole Persantine®, Aggrenox® from one route of administration to another.
Enoxaparin Lovenox®
Atenolol Tenormin®
Fondaparinux Arixtra®
Esmolol Brevibloc®
Heparin Hep-flush®, Hep-lock®
Labetalol Trandate®
Lepirudin Refludan®
Metoprolol Toprol®
Pentoxifylline Trental®
Propranolol Inderal®
Ticlodipine Ticlid®
Tinzaparin Innohep®
Warfarin Coumadin® Cardiovascular Agents: Digoxin
Digoxin is a high-alert medication because of the
Promethazine injection narrow therapeutic serum range; the therapeutic
The injectable form of promethazine is a high-alert medication because of the endpoint is difficult to quantify and digoxin toxicity
risk of damage and necrosis if it is accidentally given into the arteries, or subcu- may be life-threatening. Appropriate monitoring is
taneous tissue. Promethazine injection may cause drowsiness, confusion, seda- required.
tion and increase the risk for falls.
Promethazine injection Phenergan® injection Digoxin Lanoxin®

Methotrexate is a high-alert medication because of potential dosing errors when
weekly doses are misunderstood as “daily” doses. It can cause hepatotoxicity,
renal failure and it will suppress the immune system making patients more prone
to infection.
Methotrexate Rheumatrex®, Trexall®

...High Alert Medications

Home Healthcare

Chemotherapeutic Agents Gastrointestinal Agents: Antidiarrheals

Chemotherapeutic agents are high-alert medications because of the complex- Camphorated tincture of opium is a high alert med-
ity of therapeutic regimes, the variability of dosing and the toxic nature of the ication because of its name confusion with Opium
medications. tincture. Opium tincture contains 25 times more
morphine than camphorated tincture of opium and
Anastrozole Arimidex® therefore an error could potentially result in death.
Bicalutamide Casodex®
Bulsulfan Busulfex® Camphorated tincture of opium Paregoric®
Chlorambucil Leukeran®
Cyclophosphamide Cytoxan® Inoptropic Medications
Exemestane Aromasin® Inotropic medications are high alert because of risk
Flutamide Eulexin® of cardiac arrhythmias and hypotension associated
Fulvestrant Faslodex® with the use of the drugs. Appropriate monitoring is
Goserelin Zoladex® required.
Hydroxyurea Hydrea®, Droxia®, Mylocel® Milrinone injection Primacor®
Letrozole Femara® Dopamine injection Intropin®
Leuprolide Eligard®, Lupron® Dobutamine injection Dobutrex®
Melphalan Alkeran®
Mercaptopurine Purinethol® Potassium Injections
Nilutamide Nilandron® Potassium injection is a high alert medication be-
Tamoxifen Nolvadex® cause of potential errors in dosing, route and rate of
Toremifene Fareston® IV administration.

Diabetes Agents (oral) Potassium chloride and potassium phosphate

Diabetic agents are high-alert medications because of the risk for serious harm injection
associated hypoglycemic and hyperglycemic reactions when errors in dispens-
ing, administration and dosing have occurred. Hypertonic Sodium Chloride Injection
Hypertonic sodium chloride for injection is a high
Acarbose Precose® alert medication because of its accidental substitu-
Chlorpropamide Diabinese® tion for normal tonic solutions. Errors can result in
Exenatide Byetta® hypernatremia and death. “Hypertonic” sodium
Glimepiride Amaryl® chloride solutions have concentrations greater than
Glipizide Glucotrol® 0.9%.
Glyburide Diabeta®, Glynase®, PresTab®, Micronase®
Metformin Glucophage® Hypertonic sodium chloride for injection (3% or
Miglitol Glyset® 5% for example)
Pioglitazone Actos®
Nateglinide Starlix® Hypertonic Dextrose Injection 20% and
Pramlintide Symlin® above
Repaglinide Prandin® Hypertonic dextrose injection, 20% and above,
Rosiglitazone Avandia® is a high alert medication because of its acciden-
Sitagliptin Januvia® tal substitution for lower Dextrose solutions and
Tolazamide Tolinase® the potential harm associated with rapid infusion
Tolbutamide Orinase®, Tol-tab® including fluid overload, altered electrolytes, con-
gested states and pulmonary edema.
Diabetes Agents: Insulins
Insulins are high-alert medications because of the risk for serious harm associ- Dextrose 20%, 30%, 40%, 50% 70%
ated complex dosing regimens and the potential for hypoglycemic and hyper-
glycemic reactions when errors in dispensing and administration have occurred.
Insulin aspart Novolog®
Insulin detemir Levemir®
Insulin glargine Lantus®
Insulin glulisine Apidra® This list is for reference only and may not be considered
Insulin lispro Humalog® complete.
* 5 Million Lives Campaign. Getting Started Kit: Preventing
Insulin NPH Humulin N®, Novolin N®
Harm from High-Alert Medications. Cambridge, MA: Institute
Insulin Regular Humulin R®, Novolin R® for Healthcare Improvement; 2008. (Available at