Improve the Safety of

High
Alert
Drugs
JCI Definition
High Alert Medications:

Involve a higher percentage of errors

Cause Sentinel Events if given inadvertantly

Medications that carry higher risk for adverse

outcomes
Sound-alike, look-alike drugs

High Alert Drugs

Adrenergic Agonists

Adrenergic Antagonists

Anaesthetic Agents

Chemotherapeutic Agents (oral and parenteral)

Epidural or intrathecal
Medications
Inotropic Medications

 Sedation Agents
Narcotics/ Opiates
Radiocontrast Agents
Concentrated Electrolytes
Insulin
Anticoagulants

Dangerous Drugs

Oxycodone

Hyrdocodone

Diazepam

Temazepam

Alprazolam

Doxylamine

JCI Requirements

Policies or procedures address the

identification, location, storage and labelling.
Concentrated electrolytes not present in patient
care units unless clinically necessary.
Actions taken to prevent inadvertant
administration of concentrated electrolytes.
Concentrated electrolytes in patient care units
are clearly labelled and stored in a manner that
restricts access.

Concentrated Electrolytes
Potassium Chloride
2mEq/ml
Potassium Phosphate
3mmol/ml
Sodium Chloride 0.9%
Magnesium Sulphate
50%

Potassium Chloride 1g/10ml

Dilute in large volume

infusion.
Concentration of final
solution should not
be more than
40mmol/L.
Rate of
administration should
not exceed 20mmol/
hour.
Mix thoroughly to
avoid layering
effect.

Sodium Bicarbonate 8.4%

Correction of
metabolic acidosis.
Avoid extravasation.
IV tubing must be
carefully irrigated
with 5-10ml Normal
Saline after
administration.

Magnesium Sulphate
2.47g/5ml

Prevention and control

of seizures in toxemia
of pregnancy, acute
nephritis and other
conditions.
IV or IM.
IV Solutions dilute to
200mg/ml.
Infusion rate should not
exceed 150mg/min
except in severe
eclampsia.

Calcium Gluconate 1g/10ml

Continuous infusion in
large volume Dextrose
5% or Normal Saline.
Administer slowly at a
rate not exceeding 0.71.8mEq/min.
Avoid mixing with
Phosphates,
Bicarbonates or
Sulphates.

Potassium Dihydrogen
Phosphate 1.361g/10ml

Compatible with
Dextrose 5% or
Normal Saline.
Administered by
slow infusion to
avoid phosphate
intoxication.

Atropine 1mg/ml Inj

A non-selective
antimuscarinic with
both central and
peripheral actions.
SC, IM, slow IV or
in solution as
continuous infusion.
In case of
emergency, IV
bolus.

Adrenaline 1mg/ml Inj

Non-selective
adrenoceptor stimulant.
SC, IM, slow IV or IV
infusion.
If given IM, avoid
buttocks. Give IV if blood
circulation inadequate.
Intravenous administration
should be done with
extreme care, infusion
should be stopped when a
response is obtained.

Heparin Sodium 5000iu/ml

Initiates anticoagulation
rapidly.
Symptoms of heparininduced thrombocytopenia
include 50% reduction of
platelet count, thrombosis or
skin allergy.
Inhibition of aldosterone may
result in hyperkalemia.
Administration by motorised
pump advised.

Streptokinase 1.5Miu

Binds plasminogen and

causes plasmin activity.
IV infusion reduces
mortality in MI if infused
within 12 hours after
first symptoms.
Dilute with Dextrose 5%
or Normal Saline.

Labetalol 25mg/5ml

-antagonist with
arteriolar vasodilating
action.
Lower peripheral
resistance.
IV over 1 min or IV
infusion.
Dilute to at least 1mg/ml.

Propranolol 1mg/ml

Non-selective for adrenoceptors.

Given intravenously
for arrythmia,
thyrotoxic crisis.
IV 1mg over 1 minute,
repeated if necessary.

Ephedrine 30mg/ml

Vasoconstrictor
sympathomimetic
Acts on -receptors to
increase heart rate.
Slow IV for reversal of
hypotension from
spinal or epidural
anaesthesia.

Noradrenaline 4mg/4ml Inj

Vasoconstrictor
sympathomimetic.
Non-selective agonist.
IV infusion dilute 40mg
to 500mls, give through
central venous catheter.
Rapid IV or intracardiac
during cardiac arrest
@200mcg/ml.

Nimodipine 200mcg/ml

Smooth muscle
relaxant effect
especially on cerebral
arteries.
Administer via
infusion pump
through a Y-piece into
a central catheter; do
not add to infusion
container.
Incompatible with
PVC giving sets/
containers.

Nicardipine 2mg/2ml

Relaxes vascular
smooth muscle and
dilates coronary and
peripheral arteries.
Less reduction of
myocardial
contractility.
IV bolus or infusion
of 10-20mg/100ml.

Digoxin 0.5mg/2ml

Dose tailored to
patient age, lean
body weight and
renal function.
IV infusion for
emergencies.
Dilute 0.5mg in
500mls given over 2
hours.

Dobutamine 250mg

Must be given by
intravenous
infusion.
Diluted
concentration 0.51mg/ml,
concentrated
dilutions of 5mg/ml
must be given via
infusion pump.
Incompatible with
bicarbonate.

Dopamine 200mg/5ml

Intravenous
infusion.
Dilute to maximum
concentration of
3.2mg/ml.
Incompatible with
bicarbonate.

Pamidronate

Reconstitute with
10ml WFI and mix
well.
Dilute on 1000ml
0.45 or 0.9% NaCl or
Dextrose 5%.
Infuse over 2-24
hours.
Give in a separate IV
line, do not mix with
other drugs.

Neuromuscular Blocking
Agents

Vecuronium
(Norcuron) 4mg/ml
Rocuronium
(Esmeron) 50mg/5ml
Pancuronium
(Pavulon) 4mg/2ml
Atracurium (Tracrium)
25mg/2.5ml
Suxamethonium
100mg/2ml

Anaesthetic Agents

Frusemide 20mg/ml

Loop diuretic.
IM, slow IV or
infusion.
Tinnitus and
deafness with
large IV doses
and rapid
administration.

Sound-Alike, Look-Alike Drugs

Compounded By:
Illegible handwriting
Incomplete knowledge of new drugs
Similar packaging or labeling
Similar clinical use
Similar strengths

Sound-Alike, Look-Alike

Sound-Alike, Look-Alike

How To Improve

Independent Double-Check
A procedure in which TWO

individuals separately check

each component of the work
process.
e.g.One person calculate the
required dose; a second
individual calculates the
same dose independently of
the first person. Results are
then compared and matched

Error-prone Abbreviations
Misinterpretation of unfamiliar
abbreviation can cause harmful

medication error.
Trailing zero after
decimal point
Lonely decimal point
IU-mistaken as 10 or IV
QD or q.d.-mistaken as
qid
U or -mistaken as number 0 or 4, causing
10-fold overdose

Error-prone Abbreviations

MgSO4 mistaken as

Morphine Sulphate
MS/MS04 mistaken as
magnesium sulphate
Drug Name and Dose run together
especially drug names
ending with l can be
mistaken as 1.
Numerical dose and unit run together U
mistaken as another
0.

Storage
Ensure high-alert

medications are
not easily
accessible.
Additional
safeguards to
usage and
administration in
policy.

Storage

Storage

Storage

Labeling

Additional warning
labeling:
High Alert Drug
Dilute Before Use

Labeling

Safe Systems

Factor out human error.

Promotion of safe
practices.
Standard preparations
and dilutions.
Administration protocols.

Safe Systems

Organizational safety
infrastructure supports
training, best practices
and annual
recertification.

Safe Systems

Infusion pumps used to

administer
concentrated
solutions.
Other infusion devices
must be monitored
frequently.
Physician orders rate of
infusion for these
solutions.

Limit Access

Concentrated
electrolytes treated as
a controlled
substance, including
requirements that
restrict ordering and
establish storage and
documentation
requirements.

Is 5 Enough?

 Documentation
Expiry Date
Allergy
Appropriateness
Contraindications
Explaination
Double Check

Questions?