Hello,

Does anyone have mannitol on their high alert medication list?

Mannitol 20% bags are stored in our high alert medication sections on authorized acute care units, although it is not on our high alert medication list. When we realized it, we thought of removing it but now we are having doubts, mainly based on our expectation of possible serious consequences in case of an error. It's not on ISMP's list, but I was able to find at least one close call reported actually by Michel Cohen in Nursing, September 2008 issue, where a confusion in the total amount of mannitol had almost led to an accident:
https://journals.lww.com/nursing/fulltext/2008/09000/mannitol_mix_up.7.aspx

Recommandations are around clarifying the total content of mannitol using additional labels.

I found another interesting clinical case where inadvertent extended perfusion of mannitol had led to profound osmotic diuresis.
https://psnet.ahrq.gov/webmm/case/174/The-Forgotten-Drip

Would be very interested to know if anyone of you has it on their high alert list or has considered adding it but not and why.

Thanks a lot.

Serge Maltais, M.Sc.
Medication safety project manager
Pharmacy departement
CIUSSSE-CHUS
Sherbrooke, QC, Canada