OASIS Alert

Use this handy tool to help identify high-alert medications and how they work.

You see many of the same drugs over and over again in home care -- but that doesn't make them any easier to keep straight. Do you know which drugs you should track in M2010 -- Patient/Caregiver High Risk Drug Education?

A chart similar to the one below from the Institute for Safe Medication Practices can help you to keep track of the types of medications your patients are using that can cause significant harm if they are used in error. Post your chart in a common area or periodically e-mail it to your clinicians to help them remember which drugs require safeguards to assist in keeping your patients free from inury.

ISMP's List of High-Alert Medications

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. This may include strategies like improving access to information about these drugs; limiting access to high-alert medications; using auxiliary labels and automated alerts; standardizing the ordering, storage, preparation, and administration of these products; and employing redundancies such as automated or independent double-checks when necessary.

Note: Manual independent double-checks are not always the optimal error-reduction strategy and may not be practical for all of the medications on the list.

Background: Based on error reports submitted to the USPISMP Medication Errors Reporting Program, reports of harmful errors in the literature, and input from practitioners and safety experts, ISMP created and periodically updates a list of potential high-alert medications. During February- April 2007, 770 practitioners responded to an ISMP survey designed to identify which of these medications were most frequently considered high-alert drugs by individuals and organizations. Further, to assure relevance and completeness, the clinical staff at ISMP, members of our advisory board, and safety experts throughout the U.S. were asked to review the potential list. This list of drugs and drug categories reflects the collective thinking of all who provided input.

© ISMP 2007. Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications.

Correction: A modified version of this table that contained some erroneous material ran in the Vol. 11, No. 10 issue of OASIS Alert. Please refer instead to this corrected chart.