Abstract: Objective To ensure the high -alert medication safety of outpatient pharmacy, improve the management level of pharmaceutical affairs. Methods Using SHEL model summarizes and analyzes high -alert medication error events of outpatient pharmacy from 2010. Results High -alert medication error events rate of outpatient pharmacy reduced significantly. Conclusion Through the use of SHEL model on high-alert medication error event of outpatient pharmacy, we could make a definite error problem and find out the solutions, then improve the drug safe supply of drugs and management level, better for patient service.

Key words: high-alert medication, SHEL model, drug management, outpatient dispensary