This study aimed to analyze the safety reports of the organization of King Abdulaziz Medical City (KAMC); these safety reports included warfarin as a medication error or near-miss. The goal of this analysis is to optimize the reporting of incidents in the safety reporting system and to determine the factors contributing to errors in warfarin prescriptions. In this retrospective study, we used reports from 2013 to 2016 related to warfarin collected from the organization's safety report system

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... abase. The data were extracted and analyzed to determine the number of yearly reports, contributing factors, and person-affected outcomes. Overall, 78 incidents were reported (2013: n=4, 2014: n=19, 2015: n=22, 2016: n=33); 73% of them did not reach the patient, and 26.9% did reach the patient. Of the 26.9% (n=21) that reached the patient, 16 did not cause harm, and only 5 of the patients needed monitoring to confirm a lack of harm. There was a significant increase in warfarin-reported incidents over the years, which is an indication of an increased frequency of voluntary reporting in the system, along with a higher number of errors in warfarin prescriptions. The higher percentage of near-misses indicates a need to educate qualified healthcare providers, who are informed about fair culture and national and international safety standards for high-alert medication, about this issue. The organization implemented a new healthcare informatics system in 2015 and 2016; this new system was one of the important contributing factors, in addition to medication preparation errors and a lack of proper medication reconciliation. Short Communication High-alert medications are not necessarily more common in medication errors; however, the mistakes in these medications heighten the risk of causing patients significant harm. Warfarin has been classified as a high-alert drug by the Institute for Safe Medication Practices [1]. Medication errors and adverse drug reactions are the main cause of harm among hospitalized patients [2]. One study reported that approximately 6.5 medication-related adverse events occurred per 100 hospitalizations and estimated that more than one-quarter of them are preventable causes of ADRs [3]. Medication errors are potentially preventable causes of ADRs that can occur at all stages of the medication process, e.g., prescription, transcription, dispensing, and administration [4]. Errors resulting in preventable ADEs frequently occur at the steps of ordering and administration but are less frequent in transcription and dispensing [3]. In one study, the authors compare preventable to nonpreventable events in terms of length of stay and cost. They found that potentially preventable ADEs doubled the total length of stay and health care costs [5] . Furthermore, anticoagulant medications, including warfarin, are among the most common medications that cause errors in the hospital setting [2, 6] . Despite the implementation of electronic health records, including computerized provider order