U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
Paparella S. J Emerg Nurs. 2010;36:476-478.
Paparella S.High-alert medications: shared accountability for risk identification and error prevention. J Emerg Nurs. 2010; 36: 476-478
This article describes how lack of communication around a near miss involving a high-alert medication led to a never event. The author suggests that heightened clinician awareness of risks and potential errors could protect against adverse events.
Our other prescription drug problem.
Lembke A, Papac J, Humphreys K. N Engl J Med. 2018;378:693-695.
High-alert medications: the safeguards that you should put in place to reduce risks.
Blank C. Drug Topics. October 13, 2017.
ISMP Medication Safety Self Assessment for High-Alert Medications.
Horsham, PA: Institute for Safe Medication Practices; 2017.
Failed Interpretation of Screening Tool: Delayed Treatment
Casey A. Cable, MD; David J. Murphy, MD, PhD; and Greg S. Martin, MD, MSc
Administering and monitoring high-alert medications in acute care.
Cajanding JMR. Nurs Stand. 2017;31:42-52.
A randomized controlled trial on the effect of a double check on the detection of medication errors.
Douglass AM, Elder J, Watson R, et al. Ann Emerg Med. 2018;71:74-82.e1.
Identifying high-alert medications in a university hospital by applying data from the medication error reporting system.
Tyynismaa L, Honkala A, Airaksinen M, Shermock K, Lehtonen L. J Patient Saf. 2017 Jun 1; [Epub ahead of print].
Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study.
Thorpe JM, Thorpe CT, Gellad WF, et al. Ann Intern Med. 2017;166:157-163.
High-risk medications in hospitalized elderly adults: are we making it easy to do the wrong thing?
Blachman NL, Leipzig RM, Mazumdar M, Poeran J. J Am Geriatr Soc. 2017;65:603-607.
ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.
Horsham, PA: Institute of Safe Medication Practices; 2016.
Pharmacist medication reviews to improve safety monitoring in primary care patients.
Gallimore CE, Sokhal D, Zeidler Schreiter E, Margolis AR. Fam Syst Health. 2016;34:104-113.
Safer prescribing—a trial of education, informatics, and financial incentives.
Dreischulte T, Donnan P, Grant A, Hapca A, McCowan C, Guthrie B. N Engl J Med. 2016;374:1053-1064.
Double checking: a second look.
Hewitt T, Chreim S, Forster A. J Eval Clin Pract. 2016;22:267-274.
Preventing high-alert medication errors in hospital patients.
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
Impact of computerized physician order entry alerts on prescribing in older patients.
Lester PE, Rios-Rojas L, Islam S, Fazzari MJ, Gomolin IH. Drugs Aging. 2015;32:227-233.
Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome.
Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Circulation. 2015;131:980-987.
Emergency hospitalizations for unsupervised prescription medication ingestions by young children.
Lovegrove MC, Mathew J, Hampp C, Governale L, Wysowski DK, Budnitz DS. Pediatrics. 2014;134:e1009-e1016.
National Action Plan for Adverse Drug Event Prevention.
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2014;19:1-3,5-6.
ISMP Survey on High-Alert Medications in Hospitals and Other Inpatient Healthcare Settings.
Horsham, PA: Institute for Safe Medication Practices; 2014.
Effects of patient-, environment- and medication-related factors on high-alert medication incidents.
Manias E, Williams A, Liew D, Rixon S, Braaf S, Finch S. Int J Qual Health Care. 2014;26:308-320.
Identifying high-risk medication: a systematic literature review.
Saedder EA, Brock B, Nielsen LP, Bonnerup DK, Lisby M. Euro J Clin Pharmacol. 2014;70:637-645.
A multicenter, multidisciplinary, high-alert medication collaborative to improve patient safety: the Singapore experience.
Khoo AL, Teng M, Lim BP, Hons B, Tai HY, Lau TC. Jt Comm J Qual Patient Saf. 2013;39:205-212.
Your high-alert medication list—relatively useless without associated risk-reduction strategies.
ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5.
Consumer Leaflets with Safety Tips.
Horsham, PA: Institute for Safe Medication Practices; 2012.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364