Standard 4

Medication Safety

NSQHS Standards Standard 4 - Medication Safety


This page contains information about the first edition of the NSQHS standards. This edition has been superseded by the second edition that was endorsed by the Health Ministers in June 2017 and released in November 2017.

This latest edition addresses the gaps that were identified in the first edition, including mental health and cognitive impairment, health literacy, end-of-life care, and Aboriginal and Torres Strait Islander health.

Health service organisations will be assessed to the second edition from January 2019.

To find information and resources for the second edition, visit the Australian Commission on Safety and Quality in Health Care's new NSQHS Standards microsite.

Key messages

  1. Medicines are the most commonly used treatments in health care. As a result, medicines are associated with a higher incidence of errors and adverse events than other health care interventions.
  2. All clinicians including medical, pharmacy and nursing staff have a shared responsibility to ensure patient safety when prescribing, documenting and handling medicines.
  3. Analyse medication incidents to identify factors which may have contributed to the error and take action to reduce the risk of recurrence.


Medicines are the most common treatment used in health care. Because they are so commonly used, medicines are associated with a higher incidence of errors and adverse events than other healthcare interventions. Many of these events are costly and potentially avoidable.

Medicines can relieve symptoms, improve quality of life, and prevent or cure disease. But there are also risks associated with the use of medicines. Risks arise from errors such as prescribing the wrong medication, or using the right medication inappropriately (i.e. overprescribing). These types of errors are described as adverse drug or medicine events.

Many solutions to prevent adverse medicine events are found in standardisation and systemisation, or making things as routine and standard as possible. Other solutions for reducing medication errors include improving communication between clinicians, and between clinicians and patients; using technology to support the recording and transferring of information; and providing patient information and clinical decision support at the point of care.

The aim of this Standard is to ensure competent clinicians safely prescribe, dispense and administer appropriate medicines to patients informed about their medicines.

Facts and Figures

Based on 2006–2007 hospital admissions data, it has been estimated there are approximately 190,000 medicine related hospital admissions in Australia each year with an estimated costof $660 million.

In 2005 the Australian Council on Safety and Quality in Health Care noted that 90 percent of safety problems are based in the system, and only 10 percent in the individual.

Organisations therefore need to have an organisation-wide medication management system in place to reduce harm from medicines.


Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicine.

The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.

The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing, compounding and monitoring of medicines.

The clinician provides a complete list of patient’s medicines to the receiving clinician and patient when handing over care or changing medicines.

The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.

What might a medication system developed in partnership with patients look like?

  • The patient is provided with patient-specific medicines information that includes treatment options, benefits and associated risks.
  • The information provided to patients is in a format that meets their needs, and can be understood by the patient and their carers.
  • The medication management plan is discussed with the patient and the patient agrees to follow the plan.

Information above is taken directly from the Safety and Quality Improvement Guide Standard 4: Medication Safety, October 2012 document published in the Australian Commission on Safety and Quality in Health Care website.

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Responsibilities under Standard 4 include:

  • be familiar with, and adhere to, your organisation’s medication management policies
  • be familiar with, and use, medicines information resources
  • ensure accurate and comprehensive documentation in relation to all aspects of medication management
  • ensure accurate, safe and appropriate prescription, dispensing and administration of medicines
  • monitor patients for the intended therapeutic effect of their medicines and for the occurrence of adverse drug reactions
  • document and reconcile medications on admission, discharge and transfer of care between health care settings
  • provide information regarding medicines as a routine part of the clinical handover process, including a check that all required doses have been administered
  • engage patients and carers in all aspects of medication management, including history taking, speaking up if they suspect an error has occurred, reporting adverse drug reactions (ADRs) and in the development of their medication management plan
  • ensure familiarity with the high risk medicines used in your health service which may cause serious harm or death to a patient if they are misused
  • educate patients prior to commencement of new medicines, regarding their treatment options and potential adverse effects.

eLearning modules

Other eLearning resources

NPS Medicine Wise

South Australia Health Digital media eLearning

Available only to South Australia Health employees

CSDS courses

Demystifying the Insulin Pump
Developed by Clinical Access and Redesign Unit
The Demystifying the Insulin Pump education modules are an initiative of the Queensland Health Statewide Diabetes Clinical Network, through its Type 1 Diabetes Working Group.T... More info
0.5 hour/s

Further information

Below is a full copy of the Medication Safety contained in the National Safety and Quality Health Service Standards. It includes the criteria, items and actions required for health services to meet this Standard and is available on the Commission’s website at

  • Download Safety and Quality Improvement Guide Standard 4: Medication Safety, October 2012