OBJECTIVE:: To identify pediatric intensive care unit (PICU) clinicians' perceptions of high-alert medications and to develop a PICU-specific, high-alert medications list. We hypothesize that a PICU-specific list will include medications not identified on the Institute for Safe Medications Practices list and that the high-alert medications identified will differ by PICU clinician type (physicians, nurses, pharmacists). DESIGN:: PICU-specific multisite, institution-based survey of clinicians' perceptions of high-alert medications. SETTING:: The PICU in each of five institutions participating in the Chicago Pediatric Patient Safety Consortium. SUBJECTS:: Nurses, physicians, and pharmacists working in the PICU. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: PICU clinicians identified their top ten high-alert medications and their perceptions of each medication's risks and frequency of misuse. Weighted responses were calculated and compared to the Institute for Safe Medications Practices list and by clinician type. Results are based on 112 surveys collected from 56 nurses (response rate: 29%), 26 physicians (79%), and 30 pharmacists (71%), with 90 different medications or medication classes named. The top high-alert medications identified included intravenous potassium (weighted response: 72%), heparin (63%), and insulin (48%). PICU-specific high-alert medications (e.g., calcium [27%], phenytoin [21%], aminoglycosides [15%]) were not reported on the Institute for Safe Medications Practices list. Nurses more often cited medications with administration error risk (e.g., adenosine, calcium, p < 0.01), while physicians reported those with narrow therapeutic windows (e.g., aminoglycosides, diuretics, p < 0.01), and pharmacists identified medications with both administration and narrow therapeutic window risks (e.g., insulin, digoxin, p < 0.01). Clinicians perceived the frequency of risk of misuse of the most common high-alert medications to be at least once a year. CONCLUSIONS:: PICU clinicians identified high-alert medications not identified on the Institute for Safe Medications Practices list. Risks of the identified high-alert medications were attributed to a wide range of different stages in the medication process as well as clinicians' varying experiences in the medication process.