High-Alert and Look-Alike Sound-Alike Medications

Core Principles of High-Alert Medications and Dosing Safeguards

High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Errors involving high-alert medications may not occur more frequently than other errors, but their consequences are significantly more severe. To help healthcare organizations systematically identify these therapies, the Institute for Safe Medication Practices (ISMP) maintains and publishes recognized lists of high-alert medications across healthcare settings.

Because errors involving high-alert medications can cause serious harm, safe numerical writing rules help prevent dosing errors; not every high-alert medication has a narrow therapeutic index. A leading zero must always precede a decimal value less than one to prevent a missed decimal point and a ten-fold overdose. In contrast, a trailing zero must never follow a whole number on a medication order because it can cause a ten-fold overdose if misread. For example, failing to place a leading zero before a fractional dose or mistakenly adding a trailing zero to a whole number can cause a prescription to be read at ten times its intended strength.

Healthcare systems also implement institutional safeguards to mitigate high-alert medication hazards before medications reach the patient. Standardizing intravenous concentrations of high-alert medications reduces the chance of compounding and administration errors. Hospitals may restrict floor-stock access to selected high-alert medications and remove or tightly control concentrated electrolytes to reduce medication errors. In addition, an independent double-check involves two qualified personnel separately checking specified steps, such as a calculation or product selection, according to policy; clinical assessment and final verification remain the pharmacist's responsibility.