A

Anti-infectives

Amphotericin, vancomycin, and aminoglycosides, but may also

include others

Potassium and
concentrated
electrolytes

Injectable electrolyte preparations, for example potassium

chloride and magnesium sulphate, but may also include other
medicines

Insulin

All insulins

Narcotics and
sedatives

All opioids, sedatives may include benzodiazepines and other

sedating agents

Chemotherapy
agents

Cytotoxic chemotherapy

Heparin and other

anticoagulants

Heparins and all anticoagulants, including the New Oral

Anticoagulants
High Risk Medicines

Internationally, many safety organisations recommend that hospitals and health services identify the high-risk
medications that they use through review of incident data and published information. Once these medicines have been
identified, efforts should be made to increase the safety of their use. Increased safety may be achieved through
development of protocols, policies or guidelines to assist clinicians.
The NSW Ministry of Health has released Policy Directive PD2012_003 High-Risk Medicines Management which
requires all facilities to review medicines used within their facilities and to identify those that are high risk. Action must
then be taken to improve the use of these medicines. The National Safety and Quality Health Service Standards also
require health services to identify high-risk medicines used within the organization and take appropriate action to ensure
that they are stored, prescribed, dispensed and administered safely.
Whilst the medicines felt to be 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 allows us to identify
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.
The group of medicines is represented by the acronym - A PINCH.
The aim of this website is to heighten awareness of the harm that can be caused by A PINCH and provide actionoriented information that will assist in improvements to the management of these high risk medicines in hospitals in
NSW. This information should be assist facilities in meeting the requirements of the NSW Ministry of Health policy as well
as accreditation standards.

Table 1 Best Practice Recommendations And Tools For Monitoring - A PINCH

High Risk Medicine

A:
Anti-infectives

Specific
Medicine
(examples)
Amphotericin

Link to
information
Risk of confusion
between non-lipid and
lipid formulations of
injectable amphotericin

Best Practice
Recommendations

Tools for monitoring

practice
QUM Indicator 2.3:
Aminoglycoside
therapeutic drug
monitoring

(NPSA - UK)

(NSW TAG)

Safer use of intravenous

gentamicin for neonates
(NPSA - UK)
P:
Intravenous
Potassium and other Potassium
electrolytes
Chloride
Oral Bowel
Cleansing
Solutions

I:
Insulin
back to
A PINCH

Intravenous potassium
chloride
can be fatal if given
inappropriately
(ACSQHC)
Rapid Respnse Report
(NPSA - UK)

Electrolyte
availability MSSA 5.27
Vials of concentrated
forms of electrolytes (eg.,
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).
MSSA 5.27

Subcutaneous Insulin
Alert
(Victoria)
Subcutaneous Insulin
Audit Tool
(Victoria)
Safe and Effective use of
Insulin
in Secondary Care
(CREST - UK)
NHS Diabetes Safe Use
of Insulin Website(NHS UK)
Pennsylvania Patient
Safety Advisory:
Medication Errors with
the Dosing of Insulin:
Problems across the
Continuum
(PPSA - USA)

Sliding scale
Nil
insulin MSSA 5.7 Sliding
scale regular
subcutaneous insulin is
not used to treat elevated
blood glucose levels in
diabetic patients. OR A
standardised sliding scale
protocol is used to treat
elevated blood glucose
levels in diabetic patients.
Exception: The protocol
may allow for several
choices depending on
specific patient conditions
such as
diagnosis/weight/total
amount of daily insulin,
but the choices are
standardised among
different prescribers.
MSSA 5.7

Pennsylvania Patient
Safety Advisory: Insulin
Measures Worksheet
(PPSA - USA)
N:
Narcotics and other
sedatives

Opioids

Fentanyl and
other Analgesic
Patches
Oxycodone
Midazolam
HYDROmorphon
e

Reducing Dosing Errors

with
Opioid Medication
(NPSA - UK)
Safe Use of Fentanyl Skin
Patches
(NSW Health)
Analgesic Skin Patches
(NSW TAG)
Oxycodone (NSW
Health)

Sedation antidotes MSSA

5.13 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.
MSSA 5.13

Reducing the risk of

overdose
with midazolam
injection in adults

Neuromuscular blocking
agent availability MSSA:
5.24 Neuromuscular
blocking agents are not

QUM Indicator 6.1:

Potassium availability
(NSW TAG)

QUM Indicator 4.1:

Documentation pain
intensity
(NSW TAG)
QUM Indicator 4.2:
Written pain
management plan
(NSW TAG)
QUM Indicator 5.7:
Sedatives at discharge
(NSW TAG)

(NPSA, UK)
Medication Incidents
Involving
HYDROmorphoneand
HYDROmorphone: Highrisk analgesic(NSW
Health)

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.
MSSA: 5.24
PCA pumps MSSA 6.8
The types of patient
controlled analgesia
(PCA) pumps used in the
hospital are limited to two
or less to maximise
competence with their
use.
MSSA 6.8

C: Chemotherapeuti
c agents
back to
A PINCH

Vincristine
Methotrexate

Etoposide

Vincristine can be fatal if

administered by the
intrathecal
route(ACSQHC) ,
Safe Use of
Vincristine(NSW Health)
Improving compliance
with oral
methotrexate
guidelines(NPSA - UK)
Safe Use of Oral
Methotrexate
(NSW Health Policy
Directive)
Etoposide and Etoposide
Phosphate Products(SA
Health, Quality and
Safety Unit)

Dose calculation MSSA

10.32 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.
MSSA 10.32
Dose calculation pharmacist independent
verification MSSA 10.34
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) a double
check of the prescriber's
calculated dose (or it is
performed electronically)
before preparing and
dispensing the drug.
MSSA 10.34

QUM indicator 3.6:

Protocol based
chemotherapy
(NSW TAG)

Dose calculation - nurse

independent double
check MSSA 10.36
Nurses permanently
document (e.g., with
initials) an
INDEPENDENT
DOUBLE CHECK of the
prescriber's calculated
dose for chemotherapy
before administering the
drug.
MSSA 10.36
Drug independent double
checkMSSA: 10.38 The
drugs, actual drug
containers, doses,
diluents, and volumes
added to the diluent 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) before
dispensing/administering
the products.
MSSA 10.38
H:
Heparin and
anticoagulants
back to
A PINCH

Warfarin
Anticoagulants

Warfarin
(NSW Health)
Preventing errors related
to commonly used
anticoagulants
(The Joint Commission USA)
Actions that can make
anticoagulant
therapy safer
(NPSA - UK)

Refer to MSSA-AT and

Anticoagulant Policies
Document (when
complete)

QUM Indicator 1.3:

Enoxaparin dosing
(NSW TAG)
QUM Indicator 1.4:
Warfarin initiation
(NSW TAG)
QUM Indicator 1.5:
Warfarin dose review
(NSW TAG)
QUM Indicator 5.4:
Warfarin written
information
(NSW TAG)