[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Medications and dose calculation](https://durgical.com/en/nursing/areas/medication/) › High-alert medications

# High-alert medications

- Safe practice

These are drugs with a higher risk of serious harm when used in error; they need extra barriers such as an independent double check.

Updated Nov 12, 2026

## Key points

- Classic groups: insulins, anticoagulants, concentrated electrolytes (potassium chloride), opioids and sedatives, and chemotherapy.
- Independent double check: two people separately check drug, dose, calculation and pump programming.
- Concentrated potassium chloride is removed from ward stock: standardised mixtures are used.
- Distinct labelling and separate storage.
- Smart pumps and standardised concentrations.
- Each institution sets its exact list, based on ISMP's.

## What it is

High-alert medications are not necessarily involved in errors more often than others, but when an error happens the harm is usually serious. The Institute for Safe Medication Practices (ISMP) publishes a reference list that many institutions adapt; WHO includes them among the high-risk situations of its «Medication Without Harm» challenge, and Colombia's Ministry of Health asks institutions to standardise their list, label these drugs and store them separately. Typical groups: insulins, anticoagulants, concentrated potassium chloride and other concentrated electrolytes, opioids and sedatives, chemotherapy and some anti-infectives.

## What it requires

- A published institutional list that all staff know.
- Visible labelling and separate storage.
- Standardised concentrations and presentations.
- An independent double check at the highest-risk steps.
- Monitoring of the patient after administration.

## Components

- Insulins: risk of hypoglycaemia; confusion between units and millilitres.
- Anticoagulants (for example heparins and warfarin): risk of bleeding.
- Concentrated electrolytes (potassium, magnesium, calcium, hypertonic sodium chloride): serious, even fatal, harm when given in error.
- Opioids and sedatives: oversedation and respiratory depression.
- Chemotherapy and some anti-infectives (such as aminoglycosides).

## How it is applied (and why)

- Know your institution's list and where these drugs are kept — you cannot guard against what you do not recognise.
- Prepare without interruptions — distractions are a frequent cause of errors.
- Ask for an independent double check — two calculations done separately catch what one person misses.
- Use a smart pump and verify the programming — prevents rate errors.
- Never give concentrated potassium chloride undiluted or as a bolus; use standardised mixtures — an error can be fatal.
- Assess the patient before and after: glucose, bleeding, sedation or breathing — catches harm early.
- Report any error or near miss to the patient-safety programme — lets the system be fixed.

## In nursing practice

- Before insulin: blood glucose and timing with meals.
- With anticoagulants: signs of bleeding and clotting tests per protocol.
- With opioids and sedatives: sedation level and respiratory rate before each dose and at regular intervals. If the patient is oversedated or breathing fewer than 12 times a minute, withhold the opioid (on an infusion or PCA, stop it) and report to the provider at once.
- With concentrated electrolytes: a pharmacist's final check of the mixture and an independent double check.

## Common mistakes

- Doing the «double check» by looking at the other person's calculation (it is not independent).
- Keeping concentrated potassium ampoules on the ward.
- Confusing units with millilitres when measuring insulin.
- Not reassessing the patient after giving the drug.

## Test yourself

Think of the answer, then tap the question to see it.

## What is a high-alert medication?

One with a higher risk of causing significant harm when it is used in error, so it needs additional safety barriers.

## What does an independent double check mean?

Two people separately check the drug, dose, calculation and programming, without first seeing each other's result.

## Why is concentrated potassium chloride removed from the wards?

Because an error with it can cause serious or fatal harm; standardised mixtures are used instead.

## What are four groups of high-alert medications?

For example: insulins, anticoagulants, concentrated electrolytes, opioids and sedatives, and chemotherapy.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/high-alert-medications/)

## Connections

## Related 4

- [The rights of medication administration](https://durgical.com/en/nursing/the-rights-of-medication-administration/)
- [Giving IV medications: bolus and intermittent infusion](https://durgical.com/en/nursing/giving-iv-medications-bolus-and-intermittent-infusion/)
- [Continuous infusions: concentration and rate per kilogram per minute](https://durgical.com/en/nursing/continuous-infusions-concentration-and-rate-per-kilogram-per-minute/)
- [Subcutaneous injection](https://durgical.com/en/nursing/subcutaneous-injection/)

## In Pharmacology 6

- [Insulins](https://durgical.com/en/pharmacology/classes/insulins/)
- [Heparins](https://durgical.com/en/pharmacology/classes/heparins/)
- [Warfarin](https://durgical.com/en/pharmacology/warfarin/)
- [Potassium chloride](https://durgical.com/en/pharmacology/potassium-chloride/)
- [Opioids and antagonists](https://durgical.com/en/pharmacology/classes/opioids-and-antagonists/)
- [Morphine](https://durgical.com/en/pharmacology/morphine/)

[← All of nursing](https://durgical.com/en/nursing/)

Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: [Medication safety in high-risk situations](https://www.who.int/publications/i/item/medication-safety-in-high-risk-situations) (World Health Organization, 2019); [Mejorar la seguridad en la utilización de medicamentos. Paquetes instruccionales, versión 2.0](https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/CA/seguridad-en-la-utilizacion-de-medicamentos.pdf) (Ministerio de Salud y Protección Social de Colombia, 2015); [Nursing Pharmacology (Open RN), 2.5 Preventing Medication Errors](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Pharmacology_(OpenRN)/02%3A_Legal_and_Ethical/2.05%3A_Preventing_Medication_Errors) (Open RN, Chippewa Valley Technical College (LibreTexts), 2023); [Grissinger M. Potassium Chloride Injection Still Poses Threats to Patients. P&T 2011;36(5):241, 302](https://pmc.ncbi.nlm.nih.gov/articles/PMC3138362) (PubMed Central (US National Library of Medicine), 2011); [Nursing Fundamentals (Open RN), 11.5 Applying the Nursing Process (Comfort)](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/11%3A_Comfort/11.05%3A_Applying_the_Nursing_Process) (Open RN, Wisconsin Technical College System (LibreTexts), 2021).

## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake

Representative model, for educational purposes only.

---
Source: https://durgical.com/en/nursing/high-alert-medications/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/high-alert-medications/