Use of medications is central to modern health care, and nearly all patients visiting a hospital will receive one or more medicines during their hospital stay or upon discharge. While in the majority of cases medicines use will result in the desired outcome, medicines are not without risk, and problems or unexpected outcomes may arise.
As medicines are taken so commonly, sometimes problems can occur in their prescription, dispensing and administration which can be termed "medication incidents". A proportion of these medication incidents result in patient harm and are called "adverse drug events" (ADEs). Some ADEs result from the manner in which the medication is used (such as an error or system failure). Other ADEs are termed "adverse drug reactions" and can result from the pharmacological properties of the medication itself when it is taken alone or in combination with other medications. Adverse events associated with medications are common, affect a substantial number of people and contribute a significant burden to health care costs.
In 2000, the Australian Council for Safety and Quality in Health Care was established by the Australian Health Ministers to provide a focus of national leadership in tackling the issues of patient safety. As part of its work, in 2002 the Council commissioned a literature review of medication safety in the Second National Report on Patient Safety Report – Improving Medication Safety
]. Amongst the findings of the review was that 2–3% of all hospital admissions in Australia were medication-related. A range of errors and system failures including errors in prescribing, administration and dispensing were found to occur in hospitals in Australia. There was limited Australian research on the causes of these errors although it was recognised that most errors resulted from a series of system failures rather than the actions of particular individuals. Some commonly associated factors identified included a lack of robust systems for prescription or ordering of medications and problems in the transfer of patient information between hospital and community settings. Evidence was found to support the use of a range of strategies to improve medication safety including computerised (electronic) prescribing with decision support, adverse drug event alerting systems, bar coding, clinical pharmacist services, services to improve information transfer between different settings and individual patient medication supply in hospitals. Careful implementation of computerised prescribing with clinical decision support systems in Australia was identified as a priority. However, it was recognised that there was an urgent need for more research examining the implementation and effectiveness of the various strategies in the Australian setting.
In 2006, the former Council was replaced by the Australian Commission on Safety and Quality in Health Care. The Commission's roles include the leadership and coordination of strategies to improve safety and quality in health care through identifying issues and policy directions, providing recommendations for action and advice to Health Ministers and publicly disseminating information on safety and quality [2
The current Commission required an updated review to examine current trends in medication safety problems and progress in research on contributing factors to these problems. There was also a need to review more recent developments in research examining the implementation of, and evidence base for, strategies to improve medication safety in the Australian setting.
This paper presents Part 1 of this two-part review. Part 1 examines the extent and causes of medication incidents and adverse drug events in acute care in Australia to 2008. It is hoped this information will inform policy makers, health care professionals, managers and researchers about the areas in which significant problems with medication safety continue.
Part 2 examines the evidence for practices to improve safety in the Australian setting, barriers and facilitators to the implementation of these strategies and priorities for further research and policy-development. Part 2 is presented as a separate paper.