MODEL HIGH-ALERT MEDICATIONS POLICY & PROCEDURES

PURPOSE
To provide guidance to acute care organizations
for the safe handling and administration of
medications designated as High Alert
Medications.
To increase awareness of High Alert Medications,
thereby improving patient safety.

DEFINITION
High Alert Medications are drugs that bear a higher
risk of causing significant patient harm when they
are used in error.i

POLICY
A. The following medications are appropriate for
inclusion in a High Alert Medications policy.

Epidural infusions
Fentanyl
Heparin (>100 units, flushes exempt)
Insulin (including regular, aspart, NPH, and
glargine)
Lidocaine with epinephrine vials
Neuromuscular blocking agents
(atracurium, cisatracurium, mivacurium,
pancuronium, rapacuronium, rocuronium,
succinylcholine, vecuronium, etc)
Patient Controlled Analgesia (PCA)
infusions of any medication
Total Parenteral Nutrition (TPN) and Total
Nutrient Admixture (TNA) solutions
Oncologic agents
Moderate sedation agents (e.g., midazolam)
Anesthetic agents (e.g., propofol)
Adrenergic agonists (phenylephrine)

B. The following medications may also be

appropriate for inclusion in a High Alert
Medication policy in addition to the
medications above.
Glycoprotein IIb/IIIa inhibitors
(eptifibatide, abciximab, tirofiban)
Iron Dextran
Adrenergic antagonists agents
(e.g., esmolol)
Anticonvulsants
C. Concentrated electrolyte vials (e.g., potassium
chloride) should not be stocked in patient care
areas.

PROCEDURES
Safety procedures during the ordering, preparation,
dispensing and administration of High Alert
Medications include:
Prescribing
A. Verbal orders for High Alert Medications should
be discouraged.
B. If possible, prescribing for High Alert Medications
should be standardized using preprinted orders.
Preparation and dispensing
A. All storage locations should be clearly labeled
and separated from regular stock. If High Alert
Medications must be kept in patient care areas,
locked storage areas should be used with a
distinct High Alert Medication warning label
visibly placed on the storage bin.

The Wisconsin Patient Safety Institute enhances and promotes patient safety by advocating for
the adoption of safe practices in health care organizations throughout Wisconsin.
More resources available at www.wpsi.org.

B. If dispensing cabinets are utilized in the facility for

High Alert Medications, a reminder message
should appear on the dispense screen to alert the
caregiver to the high alert status of the medication.
Each pocket containing a High Alert Medication
should also be labeled to alert the caregiver.
C. High alert intravenous infusions should be clearly
labeled as such using a font readily
distinguishable from the rest of the label
(i.e. High Alert: Requires Double Check).
Administration
A. Caregivers should be encouraged to double check
all High Alert Medications before administering.
Double-checking is defined as:
Independently comparing the label and
product contents in hand versus the written
order or pharmacy-generated medication
administration record (MAR);
Independently verifying any calculations for
doses that require preparation (e.g., any time
the medication is not dispensed in the exact
patient-specific unit); and
Assuring the accuracy of infusion pump
programming for continuous intravenous
infusions of medications.
Note: Manual double checks are not always the
optimal error reduction strategy and may not be
practical for every High Alert Medication
administration (i.e., at small hospitals during
the night shift, and in operating rooms.) ii
B. A second provider with medication administration
training should perform and document a third
check by initialing the double-check of that item
prior to medication administration on the MAR.
C. Standardized dose calculation tables
(e.g., x ml = y mcg) should be utilized for
High Alert Medications on all patient care areas.
D. Whenever administration of a High Alert
Medication continuous intravenous infusion is
begun, a second caregiver should verify:
The 5 rights (right patient, right medication,
right dose, right time, right route);
That the intended infusion is going into the
intended channel by physically tracing the
line from the solution, through the pump,
and to the insertion site; and

That the infusion pump is programmed at the

proper rate, including correct entry of the
patients weight into the pump.
E. Any time a patient is transferred between units,
the caregiver transferring the patient and the
caregiver accepting the patient should be
encouraged to check continuous intravenous
infusions of all High Alert Medications at the
bedside. The caregiver should check for the right
patient, right medication, right rate of infusion,
and right concentration of medication versus the
written order or MAR.
F. All continuous intravenous High Alert Medication
infusions should be administered via an IV pump.
Each infusion line should be labeled with the
name of the medication being infused at the distal
ends of all tubing and across the door of the
correct IV pump channel so that two providers
can independently trace the line back to the point
of entry for confirmation.
G. In emergency situations where safety labeling
and handling precautions would delay treatment
and negatively impact care delivery, the nurse
or physician should first determine that the
urgency of a patients clinical condition warrants
bypassing double-check procedures, then
the provider administering the medication should
announce all drug therapy to another health-care
provider immediately before administration.iii

DISCLAIMER: The information in this publication was

developed by the Wisconsin Patient Safety Institute to
provide general information regarding guidelines for
medication safety. None of the information contained
herein is intended as legal or medical advice or opinion
relative to specific matters, facts, situations or issues.
Specific facts or future developments may affect the
subjects addressed in this document.
The Wisconsin Patient Safety Institute makes no
warranties, expressed or implied, regarding the
accuracy, completeness or suitability of use of these
materials. We recommend that you contact your
attorney to obtain an opinion regarding the appropriateness of using any guideline in clinical practice.

___________
i Institute for Safe Medication Practices. Medication Safety Alert!. December 2003 (Vol. 8, No. 25). Article available at
http://www.ismp.org/MSAarticles/highalert.htm (last accessed February 20, 2004).
ii

Ibid.

iii

University of Wisconsin Hospital & Clinics. UWHC Hospital Policy #8.33, High Alert Medications.