Safety and Quality > Our Work > Medication Safety > High risk medicines > Medication safety alerts and notices

Safety alerts and other guidance are classified according to the following taxonomy:

A          Anti-infectives

P          Potassium and other electrolytes

I           Insulin

N         Narcotics and other sedatives

C         Chemotherapeutic agents

H         Heparin and other anticoagulants

S          Systems

The Commission does not warrant that the list is exhaustive. There could be other alerts, advice and guidance related to other medicines or practice areas which may be relevant to you.

To encourage practice monitoring and improvement, each high risk drug class is mapped to tools validated in Australia. The tools are Medication Safety Self Assessment for Australian Hospitals and Indicators for Quality Use of Medicines in Australian Hospitals.

High risk medicines

A: Anti-infectives

P: Potassium and other electrolytes

1. Intravenous potassium chloride can be fatal if given inappropriately: Australian Commission on Safety and Quality in Health Care

2. Guideline for replacement of potassium: Victorian Therapeutic Advisory Group (PDF)

3. Policy for use of IV potassium chloride: WA Department of Health

4. IV administration of mis-selected concentrated potassium chloride: UK National Patient Safety Agency

5. Potassium chloride update: UK National Patient Safety Agency

6. Safety strategies for potassium phosphates injection: ISMP Canada (PDF)

7. Reducing risk of harm from oral bowel cleansing solutions: UK National Patient Safety Agency

Best practice recommendation

Electrolyte availability MSSA 5.27 Vials of concentrated forms of electrolytes (e.g. potassium chloride, potassium phosphate, magnesium sulfate, and sodium chloride greater than 0.9%) that require dilution before IV use are not available as ward or imprest stock and/or in automated dispensing cabinets on any patient care units (including in operating room/anaesthesia stock).

Monitoring practice tool

Potassium availability QUM indicator 6.1: Percentage of medication storage areas outside pharmacy where potassium ampoules are available.

I: Insulin


Alerts and other information

1. Insulin alert: Victorian Department of Human Services (PDF)

2. Sub-cutaneous insulin audit tool: Victorian Department of Human Services (PDF)

3. Insulin errors: ISMP Canada (PDF)

4. Insulin Safety Web Site: UK National Patient Safety Agency

5. Medication Errors with the Dosing of Insulin: Problems across the Continuum: Pennsylvania Patient Safety Authority

6. Insulin Measures Worksheet: Pennsylvania Patient Safety Authority (PDF)

Best practice recommendation

Sliding scale insulin MSSA 5.7 Sliding scale regular subcutaneous insulin is not used to treat elevated blood glucose levels in diabetic patients. OR A standardised sliding scale protocol is used to treat elevated blood glucose levels in diabetic patients. Exception: The protocol may allow for several choices depending on specific patient conditions such as diagnosis/weight/total amount of daily insulin, but the choices are standardised among different prescribers.

N: Narcotics and other sedatives


Alerts and other information

1. Oxycodone – NSW Health (PDF)

2. Fentanyl skin patches – NSW Therapeutic Advisory Group (PDF)

3. Medication incidents involving hydromorphone (Opioid): NSW Health (PDF)

4. HYDROmorphone (High Risk Analgesic): NSW Health (PDF)

5. Fentanyl skin patches: US Institute for Safe Medication Practices

6. Fentanyl skin patches: ISMP Canada (PDF)

7. Risks with high dose morphine and diamorphine injections: UK National Patient Safety Agency

8. Reducing errors with opioid dosing: UK National Patient Safety Agency

9. Reducing risk of overdose with midazolam injection in adults: UK National Patient Safety Agency

10. Fentanyl patch fatalities linked to “bystander apathy”: We ALL have a role in prevention!

11. Codeine in children – deaths prompt new safety warnings: NPS Medicinewise

12. Advancing Opioid Safety for Children in Hospitals: ISMP Canada PDF

13. South Australian Opioids for Acute Pain Resource Kit

Best practice recommendations

Sedation antidotes MSSA 5.13 Antidotes for MODERATE SEDATION and PCA/other IV infusion to treat pain and accompanying guidelines for emergency use are readily available near the point of use.

Neuromuscular blocking agent availability MSSA: 5.24 Neuromuscular blocking agents are not available as ward or imprest stock and/or in automated dispensing cabinets (except in operating room/anesthesia stock). OR If available in critical care units and/or the ED, neuromuscular blocking agents are sequestered from other ward or imprest stock medications (including those stocked in automated dispensing cabinets) and labelled with auxiliary warnings to clearly identify the drugs as respiratory paralysing agents that require mechanical ventilation when used.

Patient controlled analgesia pumps MSSA 6.8 The types of patient controlled analgesia (PCA) pumps used in the hospital are limited to two or less to maximise competence with their use.

Monitoring practice tools

Documentation pain intensity QUM indicator 4.1 (PDF): Percentage of postoperative patients whose pain intensity is documented using an appropriate validated assessment tool .

Written pain management planQUM indicator 4.2 (PDF): Percentage of postoperative patients that are given a written pain management plan at discharge and a copy is communicated to the primary care clinician.

Sedatives at discharge QUM indicator 5.7 (PDF): Percentage of patients receiving sedatives at discharge that were not taking them at admission.

C: Chemotherapeutic agents


Alerts and other information

1. Vincristine can be fatal if administered by the intrathecal route: Australian Commission on Safety and Quality

2. Vincristine audit alert – Victorian Medicines Advisory Committee (PDF)

3. Safe Administration of Vinca Alkaloid Drugs – WA Department of Health

4. Methotrexate – Victoria Therapeutic Advisory Group (PDF)

5. Methotrexate – UK National Patient Safety Agency

6. Methotrexate – Improving compliance with guidelines – UK National Patient Safety Agency

7. Methotrexate – ISMP Canada (PDF)

8. Safe use of oral methotrexate – NSW Health (PDF)

9. Fluorouracil – ISMP Canada (PDF)

Best practice recommendations

Dose calculation MSSA 10.32 Prescribers include the mg/m2 dose or area under the curve dose or mg/kg dose with all chemotherapy drug orders. Parameters are periodically reviewed (on at least a weekly basis) for prolonged hospital admissions, as current weight/Body Surface Area (BSA) may differ from admission measurements.

Dose calculation pharmacist independent verification MSSA 10.34 A pharmacist verifies that the mg/m2 dose, or area under the curve dose, listed with a chemotherapy order is correct, and documents (eg. with initials) a double check of the prescriber’s calculated dose (or it is performed electronically) before preparing and dispensing the drug.

Dose calculation nurse independent double check MSSA 10.36 Nurses permanently document (e.g. with initials) an INDEPENDENT DOUBLE CHECK of the prescriber’s calculated dose for chemotherapy before administering the drug.

Drug independent double check MSSA: 10.38 The drugs, actual drug containers, doses, diluents, and volumes added to the diluent for chemotherapy admixtures or compounded oral solutions are INDEPENDENTLY DOUBLE CHECKED by a pharmacist or a nurse (even if initially prepared by a pharmacist) and documented (e.g., with initials) before dispensing/administering the products.

Monitoring practice tool

Protocol based chemotherapy QUM indicator 3.6 (PDF): Percentage of patients receiving cytotoxic chemotherapy whose treatment is guided by a hospital approved chemotherapy treatment protocol.

H: Heparin and other anticoagulants

S: Systems