💊 Medications
High-Alert Medications Reference
ISMP high-alert medications requiring independent double-checks — anticoagulants, insulin, opioids, chemotherapy, and concentrated electrolytes.
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Anticoagulants
| Test / Parameter | Normal Range | Clinical Notes |
|---|---|---|
| Heparin (IV) | Monitor aPTT | Antidote: protamine. Never IV push undiluted. Double-check dose. |
| Warfarin | Monitor INR 2.0–3.0 | Antidote: Vitamin K, FFP, PCC. Dietary consistency for Vitamin K. |
| DOACs | No routine monitoring | Apixaban, rivaroxaban. Antidote: andexanet. Bleeding precautions. |
| LMWH (enoxaparin) | No routine monitoring | SQ administration. Do not expel air bubble. Contraindicated in HIT. |
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Insulin
| Test / Parameter | Normal Range | Clinical Notes |
|---|---|---|
| IV Insulin | Drip — q1h glucose | High-alert: double-check. Hypoglycemia risk. Have D50 available. |
| SubQ Insulin | Verify type + dose | U-100 standard. Mix: clear before cloudy. Rotate sites. |
| Sliding Scale | Check BG first | Verify glucose before giving. Document pre/post levels. |
| Insulin Pump | Check site + basal | Verify basal rate, bolus history, site integrity. |
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Opioids & Sedatives
| Test / Parameter | Normal Range | Clinical Notes |
|---|---|---|
| IV Opioids | Monitor RR, sedation | Naloxone available. Risk: respiratory depression, oversedation. |
| PCA | Double-check settings | Only patient presses button. Family cannot. Lock the pump. |
| Benzodiazepines | Monitor sedation | Flumazenil available. Caution: can precipitate seizures. |
| Propofol | RASS target | Monitor triglycerides, cardiac function. Max dose for duration. |
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Concentrated Electrolytes
| Test / Parameter | Normal Range | Clinical Notes |
|---|---|---|
| IV Potassium (KCl) | Max 10 mEq/hr peripheral | Never IV push — fatal arrhythmia. Central: max 40 mEq/hr with monitoring. |
| IV Magnesium | Max 1–2 g/hr | Monitor DTRs, RR. Antidote: calcium gluconate. |
| Hypertonic Saline (3%) | Central line only | Monitor Na+ closely. Rapid correction = osmotic demyelination. |
| Calcium | Caution: tissue necrosis | Glugonate: safer peripheral. Chloride: central line only. |
high-alertISMPmedication safetydouble checkanticoagulantsinsulin
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