PS-038 Developing a method for identifying a university hospital’s high alert medications

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There are medications that pose a higher risk of harmful effects and medication errors (high risk or high alert medications). It is possible to use existing high alert medication lists, although they reflect clinical practices in the contexts where the lists are compiled. Therefore, it is also preferable to use hospital specific safety data to customise these lists to fit the local context. Medication error (ME) reporting systems provide such data that could be used for compiling customised lists.


The study objective was to develop a method for identifying high alert medications in a university hospital by using ME and near miss reports gathered through the hospital’s ME reporting system.

Material and methods

Altogether, 18 136 MEs and near misses were reported in 2007–2013. This study was targeted to the reports where medications were coded as a contributing factor to MEs. This targeted sample included more high alert medications than a random sample (10%). Therapy groups and individual medications were identified. These were compared with the hospital’s drug consumption and Institute for Safe Medication Practice’s (ISMP) list of high alert medications,1 which is probably the most widely used high risk medication list. The reports including most reported and high alert medications (120 reports) were qualitatively analysed by applying the simplified root cause analysis.


The total sample included 249 reports with 280 medications of which 34% were ISMP’s high alert medications. The therapeutic groups most commonly related to MEs were antibacterials for systemic use (13%), psycholeptics (10%), analgesics (9%), antithrombotic agents (9%) and anaesthetics (7%). Serious patient harm (n=7) was related to cefuroxime, enoxaparin, ibuprofen, midatsolam, propofol and warfarin. Half of the MEs were related to parenteral preparations. Typical ME types were administration (34%), dispensing (18%), prescribing (15%), and documenting (15%) errors. The qualitative method deepened the understanding about key safety risks with high alert medications, drug nomenclature, formulations and administration routes, and changes in the formulary.


The method is applicable for compiling a hospital specific high alert medication list and related analysis of key process safety risks contributing to MEs.

References and/or acknowledgements

Institute for Safe Medication Practices.

References and/or acknowledgements

ISMP’s list of high alert medications in acute care settings, 2014.

References and/or acknowledgements

No conflict of interest

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