chemotherapeutic agents (Table 9). There were 323 pairs of high-alert medications, all in injection preparation form. However, the list of potential high-alert medications can vary by individuals and organizations. This study distin-quished 6 distinct variations (Warinchumrab hospital, 2009; ISMP, 2011b) shown in Tables 10 to 14; including narrow therapeutic index medications (110, 34.06%), highly concentrated electrolytes (36, 11.15%), emergency