Medication Safety


The Australian Commission on Safety and Quality in Health Care (the Commission) is an Australian Government agency that leads and coordinates national improvements in the safety and quality of health care based on the best available evidence. By working in partnership with patients, carers, clinicians, the Australian, state and territory health systems, the private sector, managers and healthcare organisations, the Commission aims to ensure that the health system is better informed, supported and organised to deliver safe and high-quality care. 

The Commission was engaged to develop Australia’s response (the Response) to the third World Health Organization (WHO) Global Patient Safety Challenge – Medication without harm (the Challenge). 

The Challenge aims to reduce severe, avoidable, medication-related harm by 50% over the next five years, globally. The Quality Use of Medicines objectives of Australia’s National Medicines Policy, are consistent with the aims of the Challenge. 

This document presents information on current medication safety programs and initiatives in Australia and recommends priority actions to deliver a positive Response to the Challenge. 

Harm from medications can be the result of an error, accident or communication problem, including: 

  1. Healthcare professionals prescribing and administering medicine in ways that increase the risk of harm to consumers 
  2. The complexity of medicine naming, dosing, indications, duration of therapy, monitoring, precautions, and interactions 
  3. Consumers misunderstanding why and how to use their medicines. 

The Challenge aims to make improvements at each stage of the medication process, including prescribing, dispensing, administering, monitoring and use. 

In Australia it is estimated that there are 250,000 hospital admissions annually as a result of medication related problems.1 Patients and clinicians report medication issues and adverse events in hospital, post discharge, in residential aged care facilities and in the community. 

Use of medications is the most common intervention made in healthcare. 

Total Pharmaceutical Benefits Scheme (PBS) government expenditure for financial year 2017–18 was $11,690 million with 204.1 million subsidised prescriptions dispensed.

The Response refines the goal and flagship areas of the Challenge for the Australian context. The goal is to reduce severe, avoidable medication errors, adverse drug events and medication-related hospital admissions by 50% by 2025. The three flagship areas of the Challenge are: 

  1. Monitoring polypharmacy and responding to inappropriate polypharmacy 
  2. Reducing harm from high-risk medicines, with a focus on insulin, opioid analgesics, anticoagulants, and antipsychotics 
  3. Improving medication safety at transitions of care, with a focus on a shared medicines list. 

The Response examines existing evidence and programs that reduce medication-related harm in acute care, primary care and aged care settings. The Response also has a focus on transitions

While the breadth of activities related to medication safety in Australia is large, there remain opportunities to improve the integration of these efforts. Improved coordination will be necessary, not only between systems but between health professionals. 

Continuing education of health professionals is required to facilitate improvements in prescribing, dispensing, administering and monitoring medicines to reduce severe, avoidable medication-related harm. 

Capturing and mapping Pharmaceutical Benefits Scheme (PBS) prescribing data for high-risk medicines can provide guidance on focus areas for intervention at a population level. For individuals, medication reconciliation and review information, shared amongst the consumer’s health management team reduces medication errors and adverse drug events, and avoids medication-related hospitalisations. Preparation and distribution of accurate medicines lists and informative, accurate and timely handover summaries well communicated to all members of the consumer’s health management team facilitates continuity of medication management. 

Raising awareness amongst consumers about the importance of accurate medicines lists and informative discharge summaries is key to wider implementation and application of the medication reconciliation and review process. The introduction of My Health Record has the potential to aid communication in an integrated care environment. 

The Response proposes 12 priority actions across the three flagship areas (Appendix B) – four priority actions to improve monitoring of polypharmacy and responding to inappropriate polypharmacy, four priority actions to reduce harm from high-risk medicines, and four priority actions to improve implementation and use of medication reconciliation at transitions of care. In addition, the Response proposes one priority action for each of the high-risk medicines – insulin, opioid analgesics, anticoagulants, and antipsychotics. Each action has a metric attached, such that progress towards the 50% reduction in severe, avoidable medication errors, adverse drug events and medication-related hospital admissions over the duration of the Challenge can be measured. 

The unifying link between the flagship areas is the consumer journey through the healthcare system. Involving and engaging consumers to safely manage their own medicines and participate in decision-making about their medicines places the consumer at the centre of their care. Increased confidence and reduced confusion about medications, are likely to help improve the consumer’s quality of life. 

A key theme of the Response is to invest in positive patient outcomes. Keeping the consumer at the centre of all initiatives will help create the shifts necessary to reduce severe, avoidable medication errors, adverse drug events and medication-related hospital admissions. 

Implementations of the priority actions outlined in the Response can lead to meaningful dialogue on how the future of the Australian healthcare system is shaped to make medication safety a national health priority. 

The Commission thanks all those that have collaborated towards the development of this Response.

For a full copy of the  "Medication without harm WHO Global Patient Safety Challenge Australian Response" report click the link below.

Medication without harm