High-Alert Medications, Electrolytes and Blood
Where small mistakes cause big harm
High-alert medications (ISMP)
Insulin · heparin and other anticoagulants · opioids · IV potassium chloride concentrate · magnesium sulfate · neuromuscular blockers · chemotherapy · hypertonic saline · sedation agents · oxytocin · TPN.
- Independent double checks per policy; smart pumps with dose limits.
- Avoid error-prone abbreviations: write "units" (not U or IU), "daily" (not QD), "every other day" (not QOD), "discharge" or "discontinue" (not D/C), "at bedtime" (not HS). No trailing zero (1 mg, not 1.0 mg); always a leading zero (0.5 mg, not .5 mg).
IV potassium: rules
- Never IV push or IM. Always diluted, on a pump.
- Usual max rate 10 mEq/h peripherally (higher only via central line with cardiac monitoring, per policy).
- Check urine output (≥30 mL/h) and kidney function first.
- Burns at the IV site: check for infiltration.
- Oral K⁺: with food and a full glass of water.
Electrolyte quick reference
| Electrolyte | Normal | Too low | Too high |
|---|---|---|---|
| Potassium | 3.5–5.0 mEq/L | Weakness, cramps, flat T waves, U waves, dysrhythmias | Peaked T waves, weakness, dysrhythmias → calcium gluconate, insulin + dextrose, albuterol, binders, dialysis |
| Sodium | 135–145 mEq/L | Confusion, headache, seizures | Thirst, confusion, seizures |
| Calcium | 8.5–10.5 mg/dL | Trousseau's and Chvostek's signs, tetany, long QT | Weakness, constipation, kidney stones, confusion |
| Magnesium | 1.5–2.5 mg/dL | Tremors, hyperreflexia, torsades | Loss of reflexes, respiratory depression |
| Phosphate | 2.5–4.5 mg/dL | Weakness (refeeding syndrome) | Itching; low calcium (kidney failure) |
Correct chronic low sodium slowly (generally ≤8–10 mEq/L in 24 h) to avoid osmotic demyelination. Ranges vary slightly by lab.
Blood transfusion
- Consent; two-person bedside check of patient ID and blood product.
- Baseline vital signs; normal saline only in the line; blood filter tubing. Adults: 18–20 G preferred (20–22 G acceptable for routine transfusion); 22–24 G for children.
- Stay with the patient for the first 15 min; go slowly at first.
- Finish each unit within 4 hours of leaving the blood bank.
Transfusion reaction
Fever, chills, back pain, hives, wheeze, low BP, dark urine, dyspnea:
1. Stop the transfusion. 2. Keep the IV open with normal saline through new tubing. 3. Vital signs; stay with the patient. 4. Notify provider and blood bank. 5. Send the bag and tubing back; collect blood and urine samples per policy.
Watch for fluid overload (TACO) in heart failure and older adults.
1. Stop the transfusion. 2. Keep the IV open with normal saline through new tubing. 3. Vital signs; stay with the patient. 4. Notify provider and blood bank. 5. Send the bag and tubing back; collect blood and urine samples per policy.
Watch for fluid overload (TACO) in heart failure and older adults.