High-Alert Medications


High-alert drugs pose a significant threat to patient safety. There are safeguards that pharmacists should put in place to reduce the risk.

Pharmacists-like all other health-care professionals-fear the same horrible scenario: the wrong drug is given to a patient, or the wrong dosage of the drug, or to the wrong patient altogether. They know full well that drug errors like these can lead to severe illness and even death.

In one of the most severe examples of a pharmacy drug error, Eric Cropp, Supervising Pharmacist at Rainbow Babies & Children’s Hospital in Cleveland, was charged with involuntary manslaughter in 2009. A tech working under him prepared the wrong chemotherapy drug dosage, resulting in the death of a two-year-old child. Cropp was sentenced to six months in prison and lost his pharmacy license.

That case, along with significantly enhanced education and open communication about medication errors, has led to heightened awareness about preventing mistakes before they occur. 

Related article: Self-Assessment Tool Can Help Improve Medication Safety

The Institute for Safe Medication Practices (ISMP) has been instrumental in bringing medication errors-in both hospital and retail settings-to the forefront. The organization has urged pharmaceutical manufacturers to make changes when drug names, delivery systems, and dosages are problematic for nurses, physicians, and pharmacists.

Pharmacies and health systems are more diligent than ever about preventing medication errors, despite the ever-increasing workload on pharmacists.

Chain drug stores understand this. Walgreens officials said it has played an active and leading role in improving pharmacy quality and safety. 

“Our pharmacy quality initiatives include numerous safety checks in each step of our multistep prescription filling process that helps to reduce the chance of human error,” said Tasha Polster, RPh, Vice President, Pharmacy Quality, Compliance, and Patient Safety at Walgreens.

Polster told Drug Topics that medications that are considered high risk because of potential drug interactions, side effects, or dosing considerations are identified and have safety restrictions and notifications that require pharmacist intervention prior to dispensing the prescription.


CVS uses a number of solutions to help ensure that high-alert medications are filled and dispensed safely. For example, the chain provides system alerts to their pharmacy teams that pertain to applicable medications during the prescription workflow process. In addition, they generate counseling alerts and provide the federally required therapy-specific Med-Guides for patients at the point of

pick-up, said Mike DeAngelis, Senior Director, Corporate Communications, CVS Health.

“Additionally, we employ propriety programs that focus on unique drug classes, as well as targeted patient populations, to ensure the dispensing of the appropriate medication, dosed at the correct levels and with the specific counselling, to ensure safe management of patient’s medication therapy,” DeAngelis said.

“Because of how seriously I take dispensing these medications and the level of scrutiny that we are under as community pharmacists, errors are less likely to happen,” said a pharmacy manager for a national drugstore chain who spoke to Drug Topics on the condition of anonymity. “We are more likely to call a physician to double check what medications the patient is currently taking, and other factors.”

High-Alert Meds-Where the Problems Are

While pharmacists are taking numerous steps to prevent errors on every medication dispensed, there are certain high-risk medications to which they must pay even closer attention, the ISMP says.

In the community and ambulatory pharmacy settings, chemotherapy drugs, antiretroviral drugs, pediatric solutions, insulin, and opioids are among the top high-alert medications, according to ISMP. 

In acute-care facilities, ISMP identifies antithrombotics, adrenergic agonists such as epinephrine, narcotics, opioids, chemotherapy agents, and hypoglycemic agents. In addition, there are several other classes of drugs that could cause significant patient harm if they are used in error.

Related error: My most serious pharmacy mistake

“Errors can happen with any med that is administered to a patient, but a lot of focus has turned to the high-risk medications,” said Tom Utech, PharmD, Vice President of Marketing for Medication Management Solutions at BD, and a former hospital pharmacist.

Chemotherapy agents, anticoagulant drugs, as well as medications for neonatal and pediatric patients, cause the most concern. “The high risk is with oncology/chemotherapy agents,” Utech said. “The error can start back in the compounding process. The nurse can do everything right, but if a compounding error occurred in the distribution process, it can still result in patient harm.”


Mistakes with insulin occur more often than with any other drug, according to Michael Cohen, RPh, president of ISMP. “It is the number one cause for elderly patients to be admitted to the hospital. People don’t properly use insulin, and community pharmacists still see it as dispensing a vial.”

Because some insulins are available only in a pen, the patient may not know how to use it, Cohen said. “There are also name mix-ups between different insulin types, such as Novolin and Novolog, or Humulin and Humalog, which are not the same insulins and have different effective time,” Cohen added.In a hospital setting, a very serious mistake can be made in dispensing U-500 for U-100 doses, as some patients are using a U-100 syringe with U-500 insulin. 

Patients refer to “syringe units” based on the U-100 syringe. “So, if they say, ‘I take 40 units’ and they are using U-500, they are really taking 200 units because of a five-fold greater concentration,” Cohen said. “Their doctor or nurse may miss this and prescribe only 40 units.”

There are both U-500 syringes and U-500 pens on the market. “One or the other should be used rather than a U-100 syringe, which confuses everyone,” Cohen said.

Insulin can also be a problem at the retail level. “When physicians send over generic names, you have to pause and look up the names, since we are in the habit of using the brand name [for insulin]. We make sure we are identifying the correct drug,” said the chain pharmacy manager.

Errors with methotrexate (brand names include Trexall and Rasuvo), originally used primarily to treat cancer, have been increasing since physicians began prescribing it to treat rheumatoid arthritis, psoriasis, and other inflammatory conditions. “It is supposed to be given once a week. Pharmacists almost killed people because physicians and pharmacists were used to typing, ‘1 tablet daily’,” Cohen said. This error is decreasing now because some e-prescribing systems will not let prescribers and pharmacists enter more than one pill weekly for methotrexate scripts.

Mistakes with opioids are also very concerning, including name confusion between hydromorphone and morphine. “A sevenfold overdose when the two are mixed up is not uncommon,” Cohen said.

Related article: Pharmacists write in: Worst mistakes, Part 1

Nurses often thought hydromorphone was a generic name for morphine, but the effort to educate them has paid off and helped prevent some errors. Cohen recommends referring to hydromorphone by its brand name Dilaudid to avoid confusion.

Create Your Own Alert List

Michael Claro Dejos, PharmD, BCPS, the Medication Safety Officer at Alfred I. duPont Hospital for Children of the Nemours Children’s Health System suggests that each health-care organization create its own list of high-alert medications and manage these medications by developing high-level error reduction strategies.

Institutions can start to develop their list by using ISMP’s high-alert list, and then tailoring it based on the medication safety assessment methods they perform in their hospitals, such as voluntary event reports, trigger tools, and informatics data, Dejos said.


For example, the high-alert list at Nemours includes antithrombotic agents, chemotherapeutic agents, neuromuscular blocking drugs, parenteral nutrition preparations and lipid emulsions, IV electrolyte replacement or riders excluding maintenance fluids, subcutaneous and IV insulin, and IV opioid infusions.

Prevention Is Never Ending

“There are thousands of items that have been changed and practices that have been changed. There are medications that killed people 20 years ago, but they no longer exist,” said Cohen. These changes have occurred because ISMP contacted the FDA and pharmaceutical manufacturers when mistakes occur. But as new mediations come onto the market and new uses are found for older drugs, vigilance is necessary.

One way to keep on top of medication errors is to complete ISMP’s Medication Safety Self-Assessment for High-Alert Medications, which provides many recommendations that encourage medication safety leaders to assess if these errors could occur in their institution. There are 60 self-assessments on opioids alone. 

“It’s a really important practice to reduce harm,” Cohen said. “This is not just pharmacists. We want to pull together people from risk management, the quality department, leadership such as vice president of the hospital, nursing staff, and physicians.”

Related article: The red pen rules: How to prevent pharmacy error

Another key method is to always have several pairs of eyes on the process. Even with advanced e-prescribing databases, both hospital and retail pharmacies insist that pharmacists, techs, and other health-care professionals double check each other, according to Fred Pane, PharmD, a former Director of Hospital Pharmacy, and senior consultant at the pharmacy consulting firm Visante Inc. “You try to introduce a couple of people in the process to make sure there are checks and balances with the bedside verification.” 

At Nemours’ facilities, the “independent double check” is required for all high-alert medications, Dejos said. “Two independent clinical staff members-doctors, nurses, or pharmacists-will check the prescribing, preparation/dispensing, and administering of these medications.” 

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