High-Alert Medication List Is Effective When Combined With Risk-Reduction Strategies

Pharmacy TimesMarch 2022
Volume 88
Issue 3

Implementation, communication, and assessment are critical steps to ensure patient safety.

High-alert medications are drugs that carry 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. This is borne out repeatedly by reports submitted to the Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP).

Based on error reports submitted to MERP, input from practitioners and safety experts, and reports of harmful errors in the literature, the institute has revised and updated the ISMP List of High-Alert Medications in Community/Ambulatory Care Settings.1

The ISMP is relying on ambulatory-care and community settings to use this updated list as a resource to identify the high-alert medications prescribed, stored, dispensed, and/or administered in their organizations or the facilities they serve. However, this is just the first step in safeguarding the use of high-alert medications. Without highly effective processes for staff members to follow to detect and prevent errors, a list will do little to increase medication safety. Similarly, a list of high-alert medications and related risk-reduction strategies that are not well understood by all staff members will have little impact on safety.

Implementing Risk-Reduction Strategies

The purpose of identifying high-alert medications is to establish specific safeguards to reduce the risk of harm with these drugs in all phases of the medication-use process. Strategies should eliminate or prevent the errors, make the errors visible, and/or mitigate the harm from errors when they occur. To be effective, the following components must be considered:

Understand the causes of errors. Effective strategies must address the underlying system-based causes of errors with each type of high-alert medication or class of medications. To learn about the causes of errors, review internal medication error reporting data and the results of any applicable root-cause analyses. Equally important, a search of the external literature should be completed to learn about errors with high-alert medications that have occurred elsewhere. Pharmacies must take steps to understand the causes of errors in the facility. If a pharmacy cannot describe how errors happened, its strategies may not be effective at targeting the risks within the organization.

Layer comprehensive strategies. A single risk-reduction strategy for each high-alert medication is rarely enough to prevent harmful errors. The keys to success include the following components:

  • A variety of risk-reduction strategies should be used simultaneously to reduce the risks associated with a particular high-alert drug. David Marx, a culture and system reliability expert, likens the relative safety of a system to a dice game, with each die representing a risk-reduction strategy in the layer of the safety net.2 Rolling a snake eye, or 1, represents failure; rolling anything else represents success. The more dice rolled, the less the risk of getting all 1s, and the safer the system will be. As noted by Marx, “in no place is the single [die] more deadly than that of health care....”2 Roll a single die, and harm is only a single failure away. Design the safety system to be a third, fourth, or fifth roll of the dice away from harm.
  • Choose strategies that provide reliable protection each time, such as automation or technology alerts, and limit reliance on strategies that require staff members to follow policies or rules or rely on memory to avoid error.
  • Risk-reduction strategies should affect as many steps of the medication-use process as feasible, given the underlying causes.
  • The best strategies will be sustainable over time.

Communicate The List and Strategies

A list of high-alert medications and associated risk-reduction strategies that is not well known to all who touch the medication-use process will have little impact on patient safety. Be sure to discuss with all staff members why the list and strategies are important, why they were created, and who they will affect. This will help staff members understand the value of the list and strategies, the medication errors and patient harm they will prevent, and why it is critical to implement each risk-reduction strategy. Make the document electronic and mobile friendly so that staff members can easily access it and quickly search it whenever needed.

Assess The Effectiveness of Strategies

Routinely audit the practice to determine the effectiveness of risk-reduction strategies for the identified high-alert medications. Also, regularly ask staff members for feedback and ideas about the high-alert medication list and associated risk-reduction strategies. Find out any concerns they may have at staff meetings, during leadership meetings, and/or via anonymous surveys. This is essential to keep all staff members engaged and to become aware of any barriers to implementing the risk-reduction strategies. Use this information to make necessary adjustments to the list and strategies.

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.


1. High-alert medications in community/ambulatory care settings. Institute for Safe Medication Practices. September 30, 2021. Accessed February 18, 2022. www.ismp.org/recommendations/ high-alert-medications-community-ambulatory-list

2. Marx D. Play with three dice, when you can. Outcome Engenuity. Accessed February 18, 2022. https://www.outcome-eng.com/ play-three-dice-can/

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