Safety and Quality > Our Work > Medication Safety > High Risk Medicines > High risk medicines resources

In the following table the Commission makes available a range of medication safety alerts, notices and guidance issued by the Australian states and territories and by international organisations using the APINCHS classification. There could be other more recent alerts, advice and guidance related to other medicines or practice areas which may be relevant to you or your organisation.

To encourage practice monitoring and improvement, each high risk medicine and system is mapped to tools validated in Australia, including Medication Safety Self Assessment for Australian Hospitals 2015  and National Quality Use of Medicines (QUM) Indicators in Australian Hospitals 2014Other medication safety assessment tools can be found here.

High risk medicines safety alerts, notices and other guidance

A: Antimicrobials

P: Potassium and other electrolytes

Alerts and other information

WA High Risk Medication Policy (includes use of IV potassium chloride): WA Department of Health 

NSW High-Risk Medicines Management Policy: NSW Ministry of Health (includes use of IV potassium chloride)

Potassium solutions: IV administration of mis-selected concentrated potassium chloride: UK NHS Improvement 

Patient safety alert: Accidental overdose from intravenous potassium chloride concentrate solutions: UK NHS Improvement

Safety strategies for potassium phosphates injection: ISMP Canada 

Reducing risk of harm from oral bowel cleansing solutions: UK NHS Improvement

Best practice recommendation

Electrolyte availability MSSA 5.9 (131A) 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).

OR (131B) Vials of concentrated electrolytes (e.g. 23.4% sodium chloride used to decrease intracranial pressure, potassium chloride used to stop the heart in cardiac surgery) are restricted to approved patient care units, stocked in limited quantities, segregated from other medicines in secure storage areas, and accompanied by protocols for use and other safeguards (e.g. warning labels).

Monitoring practice tool

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

I: Insulin

N: Narcotics and other sedatives

Alerts and other information

HYDROmorphone (High-risk medicine): Changes to Dilaudid injectable preparations Safety Alert: NSW Health

Oxycodone Safety Notice: NSW Health 

Safe use of midazolam Safety Notice: NSW Health

HYDROmorphone (High-risk medicine) Safety Alert: NSW Health

Safe storage of accountable medicines Safety Information: NSW Health

Opioids: Resources for use of opioids for the treatment of pain: SA Health

Fentanyl skin patches – Safe use Safety Notice: NSW Health

Fentanyl skin patches: NSW Therapeutic Advisory Group

Fentanyl skin patches: US Institute for Safe Medication Practices

Fentanyl skin patches: ISMP Canada

Fentanyl patch fatalities linked to “bystander apathy”. We ALL have a role in prevention! Institute for Safe Medication Practices (ISMP)

Advancing opioid safety for children in hospital: Institute for Safe Medication Practices (ISMP) Canada

Risks with high dose morphine and diamorphine injections: UK NHS Improvement

Reducing errors with opioid dosing: UK NHS Improvement

Reducing risk of overdose with midazolam injection in adults: UK NHS Improvement 

Best practice recommendations

Sedation antidotes MSSA 5.8 (115) 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: 5.9 (128A) Neuromuscular blocking agents are not available as ward or imprest stock and/or in automated dispensing cabinets (except in operating room/anesthesia stock).

OR (128B) 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 6.11 (161) 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

Safe Use of Vincristine Safety Alert: NSW Ministry of Health 

Methotrexate – Improving compliance with oral methotrexate guidelines and safety alert: UK NHS Improvement 

Preventative guidance: Wrong route administration of chemotherapy: UK NHS Improvement

Dispensing vincristine: Best Practice #1: Targeted Medication Safety Best Practices for Hospitals: ISMP 

Oral chemotherapy – Analysis of incidents: ISMP Canada Safety Bulletin

Methotrexate: inadvertent daily administration: ISMP Canada

Fluorouracil RCA analysis – ISMP Canada

Best practice recommendations

Dose calculation MSSA 10.19 (281) 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 10.19 (283) 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 or electronically) a double check of the prescriber’s calculated dose (or it is performed electronically) before preparing and dispensing the medicine.

Dose calculation nurse independent double check MSSA 10.19 (285) Nurses permanently document (e.g. with initials or electronically) an INDEPENDENT DOUBLE CHECK of the prescriber’s calculated dose for chemotherapy before administering the medicine.

Drug independent double check MSSA: 10.19 (287) The base solution and all additives (including the drug, dose, volume drawn into each syringe, diluents, actual drug containers) 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 or electronically) before they are added to the final product.

Monitoring practice tool

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

H: Heparin and other anticoagulants

S: Systems

Alerts and other information

Inadvertent wrong route injection: Identification of Post-Injection Syndrome Olanzapine Pamoate Long Acting Injection Safety Notice: NSW Health 

Wrong route errors with oral medication Safety Notice: NSW Health 

Wrong route administration audit tool: Victorian Department of Human Services

Correct identification of medication and solutions for epidural anaesthesia and analgesia Safety Notice: NSW Health

Promoting safer measurement and administration of liquid medicines via oral and other enteral routes: UK NHS Improvement

Lowering the risk of medication errors: Independent double checks for patient controlled analgesia: ISMP Canada

High alert drugs and infusion pumps: Extra precautions required: ISMP Canada

Best practice recommendations

Use of oral syringes MSSA 6.11 (157) Specially designed oral syringes, which cannot be connected to IV tubing, are used for dispensing/administering oral liquid solutions.

Use of infusion pumps MSSA 6.11 (166) General infusion pumps with SMART PUMP TECHNOLOGY are in use with full functionality employed to intercept and prevent wrong dose/wrong infusion rate errors due to misprogramming the pump, miscalculation, or an inaccurately prescribed dose or infusion rate.

Epidural infusion pumps MSSA 6.11 (171) Only one type of epidural infusion pump is used and is different from general infusion devices used in the organisation.

Use of bar-coding at point-of-care MSSA 10.19 (295) If bar-coding at the point-of-care is used for medication administration, an interdisciplinary team reviews metrics from the system, including the percent of medicines with a readable barcode, scanning compliance rates, and bypassed or acknowledged alerts, and any barriers associated with using the technology are addressed to maximise the safe use of the system.


Additional resources for High Risk Medicines

General principles and useful resources for best practice in management of all high risk medicines, and relevant links to validated tools, are provided below:

NSQHS Standard 4. Medication Safety 

Clinical Excellence Commission (CEC) Medication safety and Quality: High-risk medicines

NSW Therapeutic Advisory Group (NSW TAG) High Risk Medicines Protocols and Guidelines

Government of South Australia, SA Health High risk medicines

Tasmanian Government, Department of Health and Human Services High-risk Medication Management Policy

Victorian Government Department of Health & Human Services High-risk medicines

Government of Western Australia, Department of Health High risk medications policy

Western Australia Therapeutic Advisory Group (WATAG) High-risk Drugs

Department of Health Therapeutic Goods Administration

Institute for Safe Medication Practices (ISMP) ISMP High-Alert Medications

Institute for Safe Medication Practices (ISMP)

Institute for Safe Medication Practice Canada

NHS England medication safety resources