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High risk medicines and systems

High risk medicines are medicines with an increased risk of causing significant patient harm or death if misused or used in error. It’s important health professionals have procedures in place to manage high risk medicines safely.

About high risk medicines

High risk medicines include medicines that have a very small safe dose range, can be dangerous if given the wrong way, or where mistakes in the medicines management system can lead to harm.

Mistakes don’t happen often with these medicines, but when they do, the consequences can be much worse.

Policy and categorisation of high risk medicines may vary between states, territories and healthcare settings so its important health organisations have their own systems and processes in place for these medicines.
 

Classification of high risk medicines

What counts as a high risk medicine can vary depending on the medicines and the types of patients treated.

In Australian hospitals, the acronym APINCHS is commonly used to help healthcare workers identify medicines that have a high potential to cause harm.

The APINCHS acronym stands for: Antimicrobials, Potassium and other electrolytes, Insulin, Narcotics (opioids) and other sedatives, Chemotherapeutic agents, Heparin and other anticoagulants, and Systems.

The APINCHS classification provides a framework to assist health professionals to identify high risk medicines.

AAntimicrobials
  • Aminoglycosides: gentamicin, tobramycin and amikacin
  • vancomycin
  • amphotericin – liposomal formulation
PPotassium and other electrolytes
  • Injections of concentrated electrolytes: potassium, magnesium, calcium, hypertonic sodium chloride
IInsulin
  • All insulins 
NNarcotics (opioids) and other sedatives
  • hydromorphone, oxycodone, morphine, fentanyl, alfentanil, remifentanil and analgesic patches
  • Benzodiazepines: diazepam, midazolam
  • thiopentone, propofol and other short term anaesthetics
CChemotherapeutic agents
  • vincristine, methotrexate, etoposide, azathioprine
  • Oral chemotherapy
HHeparin and other anticoagulants
  • Heparin and low molecular weight heparins (LMWH): dalteparin, enoxaparin
  • Warfarin
  • Direct oral anticoagulants (DOACs): dabigatran, rivaroxaban, apixaban
S Systems 
  • Medication safety systems such as independent double checks, safe administration of liquid medications, standardised order sets and medication charts etc.

High Risk Medicines eLearning

The High Risk Medicines eLearning modules support health professionals to understand and manage high risk medicines.

The modules are available for health organisations with an approved workplace email domain. You can use the approved list of health service organisation email domains to check if your health organisation has access to the module, or you can contact the helpdesk to gain access.

 

Access eLearning module

 

Technical support and further information about the module is available on the High Risk Medicines Education website.

 

Resources and best practice recommendations

We have a range of information, resources and best practice recommendations for high risk medicines. These resources are created by a range of Australian and international organisations.

Best practice recommendation

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

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).

Best practice recommendation

Sliding scale insulin is not used to treat patients with hyperglycaemia. Regular antihyperglycaemic therapy is prescribed to treat diabetics, with supplemental insulin only added to treat hyperglycaemia as necessary in accordance with established protocols.

Best practice recommendations

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 agents are not available as ward or imprest stock and/or in automated dispensing cabinets (except in operating room/anesthesia stock).

OR

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.

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

Best practice recommendations

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.

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.

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.

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.

Best practice recommendations

Specially designed oral syringes, which cannot be connected to IV tubing, are used for dispensing/administering oral liquid solutions.

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.

Only one type of epidural infusion pump is used and is different from general infusion devices used in the organisation.

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.

Last updated: 20 March 2026