APINCHS classification of high risk medicines

In the acute sector in Australia, the ‘APINCHS’ acronym and classification assists clinicians to focus on a group of medicines known to be associated with high potential for medication-related harm.

APINCHS safety improvement list

The original classification used in Australia was APINCH. An ‘S’ for ‘systems’ has been added to include other evidence-based practices known to improve safety such as independent double-checks and safe administration of liquid medicines by using oral dispensing syringes.

A Antimicrobials

Aminoglycosides: gentamicin, tobramycin and amikacin


amphotericin – liposomal formulation

P Potassium and other electrolytes Injections of concentrated electrolytes: potassium, magnesium, calcium, hypertonic sodium chloride
I Insulin All insulins  
N Narcotics (opioids) and other sedatives

hydromorphone, oxycodone, morphine, fentanyl, alfentanil, remifentanil and analgesic patches  

Benzodiazepines: diazepam, midazolam  

thiopentone, propofol and other short term anaesthetics

C Chemotherapeutic agents

vincristine, methotrexate, etoposide, azathioprine

Oral chemotherapy

H Heparin and other anticoagulants

Heparin and low molecular weight heparins (LMWH): dalteparin, enoxaparin


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

Useful resources for high risk medicines including safety alerts, notices and other guidance can be accessed here.

HRM risk reduction strategies

The National Safety and Quality Health Service (NSQHS) Standard on Medication Safety requires health services to identify HRMs used within the organisation and take appropriate action to ensure that they are stored, prescribed, dispensed and administered safely.

It is important to note that a single risk-reduction strategy for each HRM is rarely capable of preventing patient harm. When seeking to reduce the likelihood of harm from HRMs in healthcare settings, a range of strategies need to be considered to promote safer use or decrease the opportunity for misuse or error. The institute for Safe Medication Practices (ISMP) recommends1:

  • Layering numerous risk-reduction strategies together to address the targeted risk
  • Using strategies that impact as many steps of the medication use process as feasible such as storage, prescribing, dispensing, administration and monitoring
  • Bundling low-leverage risk reduction strategies, such as staff education and passive information, with high-leverage strategies such as
    • Forcing functions and fail safes
    • Maximising access to information
    • Limiting access or use
    • Constraints and barriers
    • Standardisation and simplification.

As a minimum, health service organisations can use the ‘APINCHS’ list of medicines to:

  • Develop a list of high risk medicines used within their organisation
  • Guide identification of potential risks with these medicines and the systems used in medication management
  • Introduce a range of risk-reduction strategies.

Risk-reduction strategies should be prioritised, and based on an assessment of how HRMs are managed within the organisation using audits, incident analysis, risk assessment tools and benchmarking activities. This should be done in consultation with the healthcare organisation’s governance group responsible for medication management, for instance the Drug and Therapeutics Committee.

A recommended approach in prioritising work, as well as determining whether medication safety risks are recorded on the organisation’s risk register, is to use a risk matrix to assess potential risk level and likelihood of occurrence.


1 Institute for Safe Medication Practices (ISMP) (US). Medication Safety Alert! 4 April 2013. Your high-alert medication list – relatively useless without associated risk-reduction strategies. https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=45 (accessed September 2017).