While the medicines identified as high-risk may vary between hospitals and clinical units depending on the types of medicines used and patients treated, analysis of incident data and review of the published literature identified a group of medicines that should universally be considered as high-risk. These medicines include anti-infective agents, anti-psychotics, potassium, insulin, narcotics and sedative agents, chemotherapy and heparin and other anticoagulants. These medicines are represented by the acronym 'A PINCH'.

The poster below can be used to assist hospitals in raising awareness of A PINCH medicines.

To assist hospitals in monitoring risks associated with high-risk medicines, the tool below can also be used to monitor local implementation and compliance with the NSW Health High-Risk Medicines Management Policy (PD2020_045).

'A PINCH' Table

The table below provides:

  • Examples of high-risk medicines
  • Links to information and recommendations for specific drugs covered by A PINCH.
  • Links to selected clinical indicators from the National Quality Use of Medicines in Australian Hospitals (QUM Indicators) to support hospitals in the monitoring of high-risk medicines use.
High-Risk Medicine Groups
Examples of medicines
Link to
Link to
QUM Indicators
A: Anti-infective Amphotericin
Non-lipid and lipid formulations of injectable amphotericin
2.3-Duration of empirical aminoglycoside therapy
P: Potassium and other electrolytes Injections of potassium, magnesium, calcium, hypertonic sodium chloride High-Risk Medicine Management Policy Directive Potassium (Intravenous) Standard
(NSW Health)
6.1-Potassium ampoule storage outside pharmacy
I: Insulin All insulins Safe Administration of Medication Pen Devices
(Clinical Excellence Commission)
Know your insulins - Poster
(NSW Therapeutic Advisory Group)
N: Narcotics (opioids) and other sedatives Hydromorphone, oxycodone, morphine
fentanyl, alfentanil, remifentanil and analgesic patches,
for example, diazepam, midazolam.
Thiopentone, propofol and other short term anaesthetics
High-Risk Medicine Management Policy Directive
Hydromorphone Standard

(NSW Health)
Opioid Skin Patches are High Risk Medicines
(NSW Therapeutic Advisory Group)
Quick Steps through Opioid Management
(Agency for Clinical Innovation)
Safe Use of Fentanyl Skin Patches
(NSW Health)
4.1-Documentation of pain intensity
4.2-Pain management plan at discharge
5.7-Sedatives at discharge
6.3-Parenteral pethidine
C: Chemotherapeutic agents Vincristine
High-Risk Medicine Management Policy Directive Vincristine Standard
(NSW Health)
3.6-Protocol based chemotherapy
H: Heparin and anticoagulants warfarin
High-Risk Medicine Management Policy Directive
Anticoagulant Standard

(NSW Health)
Intravenous Unfractionated Heparin Recommended Standard (Clinical Excellence Commission)
NOAC Guidelines
(Clinical Excellence Commission)
Perioperative Management of Anticoagulant and Antiplatelet Agents
(Clinical Excellence Commission)
1.3-Enoxaparin dosing
1.4-Warfarin initiation
1.5-Warfarin dose review
1.6-AF patients discharge on anticoagulant
5.4-Warfarin written information
Other High-risk medicines
identified at Local Health
District/ Facility/Unit level which do not fit the above categories.
High-Risk Medicine Management Policy Directive Paracetamol Standard
(NSW Health)
NOAC Guidelines
(Clinical Excellence Commission)

Examples of dose specific safety measures

Transdermal patches:

  • Confirmation from the prescriber should be sought if multiple patches are to be applied.
  • The time of application, site of application and time of removal should be documented on the medication chart.
  • Transdermal patches should not be exposed to extremes of temperature.
  • Transdermal patches should not be cut.
  • Transdermal patches containing opioids should be securely disposed of, for example, in sharps bin.

Modified release oral medicines, for example, slow release formulations:

  • These formulations should not be dissolved, divided (unless scored), or crushed prior to administration.
  • Pharmacy department should be contacted for advice on an alternative formulation, or dose preparation, if a patient has difficulty swallowing.

Medicines inhaled using devices:

  • Ensure the patient understands and is able to use the devices correctly.
  • Ensure the device settings are correct for each medicine delivery
  • Ensure use of the correct dose form and strength.

Parenteral fluids:

  • When available, high-risk medicines are purchased in a form closest to the dilution and strength in which they are to be administered, so as to minimise opportunity for error in ward-based preparation. Pre-mixed infusion of fluids of high-risk medicines are to be used in preference to those locally prepared.
  • The need to vary from pre-mixed infusion strengths is clearly indicated and documented in the patient's health care record.
  • Infusion pumps with intelligence-activated (smart) pumps are to be used, where available, to screen for dose, dilution and rate of administration. Intelligence checks are not to be bypassed without obtaining the clinical expertise of a senior clinician.