Medication Safety: Strategies for the Safe Use of High-Alert Medications

High-alert medications (HAMs) are medications with an increased risk of causing patient harm if used in error. Medication errors with these drugs are not necessarily more frequent, but their consequences can be much harsher, leading to severe injury, permanent disability, or death. Some examples of HAMs include antithrombic agents, anticoagulants, insulin, opioids and narcotics, intravenous concentrated electrolytes, chemotherapeutic agents, neuromuscular blocking agents, and anesthetic agents.¹ These medications often have narrow therapeutic indices, complex dosing requirements, and look-alike/soundalike names and/or packaging.

HAM-related errors occur throughout the medication-use process and across a variety of health care settings. Although HAM errors can occur at any time, they are most common during the prescribing and administration phases.² Therefore, regularly reviewing strategies for maintaining the safe use of HAMs is a good idea.

Strategies for Safe Medication Management

To mitigate medication errors with HAMs, health care facilities must implement a multifaceted approach that focuses on system-based strategic safeguards layered throughout the entire medication process.

Standardization

Standardized processes and uniform procurement, storage, preparation, and administration practices of HAMs will reduce variability, thereby reducing the risk of medication errors. Simplify by limiting the number of available drug concentrations and stock quantities to reduce confusion. Eliminate all nonmetric measurements (eg, teaspoons) and use only metric units (eg, milliliters) for oral liquid preparations. Use appropriate metric-only measuring devices.³

Storage and physical safeguards

Restrict access to HAMs. Only authorized personnel should have access to HAMs, and these medications should be stored in a secure location. Segregate and/or differentiate look-alike/soundalike medications by storing them in separate locations and/or using tall man lettering (eg, hydrALAzine and hydrOXYzine). Apply warning labels to all HAMs and their storage areas to raise awareness of their high-risk nature.

Utilizing technology

Technology helps reduce errors with HAMs by minimizing manual, human intervention and maximizing safety checks. Technologies such as computerized physician order entry and clinical decision support systems eliminate errors caused by illegible handwriting and verbal orders. They also provide real-time alerts for potential drug interactions, allergies, incorrect dosages, and contraindications at the time of prescribing, thereby reducing prescribing errors. Automated dispensing cabinets and robotics automate the preparation and dispensing of medications, reducing human error. Smart infusion pumps are intelligent intravenous pumps that incorporate dose error reduction software for high-alert intravenous medications.⁴

Redundancies and checkpoints

Reducing errors with HAMs by creating redundancies and checks is based on the idea that humans are fallible. Implementing multiple independent processes and/or individuals verifying the same information allows for the detection of an error before it reaches the patient, prevents confirmation bias, and increases system reliability.⁵ These redundancies and checks can include independent double checks, automated alerts, checklists and protocols, and matching patient information.

Antidote availability

Antidotes are therapeutic agents used to counter the toxic effects of HAMs. Having these on hand is crucial for minimizing harm or death, as their lifesaving effects depend on timely administration. Antidotes work through a variety of methods: binding and neutralizing the offending substance (eg, digoxin immune fab for digoxin toxicity), antagonizing end-organ effects (eg, atropine for organophosphates), inhibiting conversion (eg, acetylcysteine for acetaminophen), and competitive receptor blockade (eg, naloxone for opioids).⁶

Education and Culture

To effectively reduce the risks associated with HAMs, comprehensive health care professional and patient/caregiver education, along with a strong safety culture, is paramount.

Although systemic safeguards are crucial, ongoing health care professional education provides a critical layer of defense. Provider education is a cornerstone strategy for reducing the risks associated with HAMs, thus enabling improved safety protocols and appropriate monitoring. This education must include safety protocols, monitoring parameters, best practices, standardized procedures, and the use of technology to minimize errors during prescribing, administration, and monitoring.

A strong culture of safety enables staff to apply this knowledge effectively by encouraging the reporting of errors without fear of reprisal. This allows staff to prioritize recognizing, reporting, and reducing risks to prevent patient harm. Therefore, staff can learn from mistakes and implement improvements to reduce these errors in the future.

Patient and caregiver education serves as an imperative final safety check to reduce the risk of harm. When patients are fully informed about their HAMs, they are better able to manage their risk of harm by confirming that they have received the correct medication in the proper dose. They are also more likely to follow complex dosing schedules and adhere to regimens and to recognize the early signs of adverse effects and/or toxicity.

Monitoring and Quality Improvement

Monitoring and quality improvement (QI) are essential, continuous processes required to reduce the risks associated with the use of HAMs.

Monitoring encompasses the ongoing surveillance of medication use to gather data and track performance. Key parameters include error and near-miss tracking, performance metrics, and patient outcomes.

QI uses the data gathered from the monitoring phase to implement improvements. Data-driven interventions involve analyzing and monitoring data to determine the root cause of errors and identify areas for improvement. QI initiatives implement targeted evidence-based best practices. The QI process ensures these improvements are implemented and monitored to verify their effectiveness. This creates a system that continually adapts to changing situations to minimize the risks associated with HAMs.

Conclusion

The safe use of HAMs requires more than careful consideration: It demands a vigorous, multifaceted system of defense. The strategies outlined, including standardization, integration of technology, a shift toward safety culture, and comprehensive education and training for health care professionals, patients, and caregivers, work synergistically to reduce the risks associated with HAMs. Continuous monitoring and QI ensure the systems remain robust and adaptive. Through prioritizing these proactive, system-based methodologies, health care professionals can reduce the risk of harm and ensure HAMs are used safely.

REFERENCES

1. ISMP list of high-alert medications in acute care settings. Institute for Safe Medication Practices. October 2018. Accessed December 11, 2025. https://www.ismp.org/sites/default/files/attachments/2018-10/highAlert2018new-Oct2018-v1.pdf

2. Cottell M, Wätterbjörk I, Hälleberg Nyman M. Medication-related incidents at 19 hospitals: a retrospective register study using incident reports. Nurs Open. 2020;7(5):1526-1535. doi:10.1002/nop2.534

3. Safe medication administration: facilitator guide. Agency for Healthcare Research and Quality. Updated July 2023. Accessed December 11, 2025. https://www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-fac-guide.html

4. Collins S. Technology can reduce medication errors; pharmacy must embrace it. American Pharmacists Association. December 7, 2024. Accessed December 11, 2025. https://www.pharmacist.com/Blogs/CEO-Blog/Article/technology-can-reduce-medication-errors-pharmacy-must-embrace-it

5. McMullan RD, Urwin R, Wiggins M, Westbrook JI. Are two-person checks more effective than one-person checks for safety critical tasks in high-consequence industries outside of healthcare? a systematic review. Appl Ergon. 2023;106:103906. doi:10.1016/j.apergo.2022.103906

6. Chacko B, Peter JV. Antidotes in poisoning. Indian J Crit Care Med. 2019;23(suppl 4):S241-S249. doi:10.5005/jp-journals-10071-23310