Abstract: Objective: To describe the characteristics and analyze risk factors for medication near-miss errors stemming from the NICU work system based on self-incident reports from staff nurses. Methods: Data on medication errors were collected from a convenience sample of 42 NICU nurses at four hospitals in Beijing from January 2014 to December 2015. The ASSESS-ERRTM Medication System Work sheet was used to collect the data of possible system risk factors resulting from the near-miss error. Grey Relational Analysis was used to examine the associations between the five medication-use processes and the 10 risk elements. Results: A total of 134 medication near-miss errors were reported by nurses. The order prescribing stage had the most medication near-miss errors (58.2%). The highest systemic risk factor was critical drug information missing (ξ2=0.425), and the rank of risky stage was: repackaging prescribing dispensing administering monitoring/ education. Conclusion: Analyzing the possible system risk factors resulting from the near-miss error could be a useful method for nurses to generate hierarchical risk-control strategies and improve medication safety for neonates.