Pharmacy AI · Module 3 · Unit 3 — Identifying High-Risk Patients & High-Alert Medicines

Identifying High-Risk Patients & High-Alert Medicines

Aim — To identify high-alert medicines and high-risk patients, recognise the specific hazard, and apply the correct risk-reduction (safety) action. Duration 60 minutes · One case per student · 100-mark rubric · Pass 50%.

Case —
Score —
Result —
◐ Theme

New to high-alert medicines? Start here

Some medicines cause serious harm when used in error, and some patients are more vulnerable to harm. Your job is to spot both and add extra safeguards:

  1. Flag high-alert medicines — anticoagulants, insulin, opioids, cytotoxics (e.g. methotrexate), concentrated electrolytes (e.g. IV potassium), narrow-therapeutic-index drugs (e.g. digoxin).
  2. Flag high-risk patients — elderly, poor kidney/liver function, pregnancy, children, low body weight, many medicines (polypharmacy).
  3. Name the specific hazard — what could actually go wrong here?
  4. Apply the safety action — independent double-check, monitoring, dose verification, clear labelling, or hold & clarify a dangerous order.

Unsure on a case? Open “Need a hint?” in the station.

Student tasks

Examples of high-alert medicines

ClassClassic catastrophic error
Anticoagulants (warfarin, heparin)Bleeding; wrong heparin concentration; interactions raising INR
InsulinHypoglycaemia; "U" misread as a zero (10× overdose)
OpioidsRespiratory depression, especially opioid-naive/elderly/renal
MethotrexateTaken DAILY instead of WEEKLY — fatal toxicity
Concentrated IV potassiumFatal arrhythmia if given undiluted as a bolus
Vincristine (chemo)Fatal if given intrathecally instead of IV
Digoxin (narrow TI)Toxicity with renal impairment / low potassium

Faculty assessment rubric

CriteriaMarks

Choosing an unsafe action for a life-threatening high-alert order (e.g. dispensing daily methotrexate, undiluted IV potassium) is a patient-safety error and fails the station.

Candidate & case assignment

Practical record & assessment

Complete the risk review and submit to generate your assessment, then write and submit your report.