High alert medications:\n• Insulin (all types)\n• Heparin (IV and SubQ)\n• Warfarin\n• Concentrated electrolytes (KCl, hypertonic saline)\n• Opioids (morphine, fentanyl)\n• Chemotherapy agents\n• Neuromuscular blocking agents\nRequire: double-nurse verification, special storage, extra monitoring

1. Right PATIENT (2 identifiers)\n2. Right DRUG\n3. Right DOSE\n4. Right ROUTE\n5. Right TIME\n6. Right DOCUMENTATION\n7. Right REASON\n8. Right RESPONSE\n9. Right EDUCATION\n10. Right to REFUSE

Most dangerous: RESPIRATORY DEPRESSION (RR <12)\nANTIDOTE: Naloxone (Narcan) — short-acting, may need repeat doses\nHold if RR <10-12 (per order)\nOther concerns: constipation (prophylactic laxative!), urinary retention, hypotension\nSchedule II — special documentation required

HOLD metformin:\n• Before contrast dye/CT scan (hold 48hr before AND after)\n• If eGFR <30 mL/min (contraindicated)\n• eGFR 30-45 (use with caution)\n• Before surgery\n• If patient becomes acutely ill\nReason: Risk of lactic acidosis with contrast and renal impairment

REGULAR insulin (clear) is the ONLY insulin given IV\nAll other insulins: SubQ only\nMemory trick: "Regular goes IV Regular-ly"\nWhen mixing insulins: Draw Regular (clear) BEFORE NPH (cloudy)\n"Clear before cloudy"

• Never stop abruptly — taper to prevent adrenal crisis\n• Monitor blood glucose (steroid-induced hyperglycemia)\n• Take with food (GI irritation)\n• Increased infection risk — masks fever\n• Long-term: osteoporosis, Cushing syndrome\n• Supplement calcium + Vitamin D for bone protection\n• Avoid live vaccines

ACE Inhibitors (lisinopril, enalapril):\n• Block conversion of angiotensin I → II\n• Side effect: DRY COUGH (10-15%)\n• Risk: Angioedema (rare but life-threatening)\nARBs (losartan, valsartan):\n• Block angiotensin II receptors\n• NO dry cough\n• Alternative when ACE inhibitor cough is intolerable\nBoth: Contraindicated in pregnancy, monitor potassium and renal function

Therapeutic trough: 10-20 mcg/mL (15-20 for serious infections)\nInfuse SLOWLY (over 60 min minimum) — prevents Red Man Syndrome\nRed Man Syndrome: Flushing, rash on face/neck — slow infusion, give diphenhydramine\nMonitor: Renal function, hearing (ototoxicity), trough levels\nANTIDOTE: None — supportive care