How to Prevent Medication Errors

Quick answer

Medication errors are most likely at handover points — a new prescription, a hospital admission, a discharge, a new clinician. The most effective thing an individual can do is carry one accurate, current list and hand it over at each of those moments, rather than reconstructing it from memory each time.

Research reviewing Australian data from 1988 to 2021 estimated that at least 250,000 hospital admissions a year in Australia are medication related, costing roughly $1.4 billion, and that around two-thirds are potentially preventable. That last figure is the one worth sitting with: most of this harm is not inevitable.

What counts as a medication error

A medication error is any preventable event that leads to, or could lead to, inappropriate use or harm. It covers more than the obvious wrong-drug scenario:

The wrong medicine, dose, strength or form
The right medicine at the wrong time, or a missed dose
A medicine given despite a documented allergy
Two medicines that interact, prescribed by different people
A medicine continued long after it should have stopped
Instructions that were misread or misunderstood

Note how many of those are information failures rather than clinical mistakes. Someone did not know something that was true.

Where errors actually happen

Stage	What can go wrong
Prescribing	An incomplete history — an allergy or another medicine not known
Dispensing	Similar names, similar packaging, unclear instructions
Administration	Wrong dose or time, doubling up, a dose taken twice by accident
Monitoring	Nobody reviewing whether it is still needed or still working
Transitions	Admission and discharge, where lists change and get lost

Transitions are the biggest single risk, which is why they get the most attention nationally — and why the discharge conversation matters so much. See the coming home from hospital checklist.

What the health system does about it

Australian hospitals work to the Medication Safety Standard within the National Safety and Quality Health Service Standards. In practice that means things like medicine reconciliation — formally comparing what you were taking before admission with what is prescribed now — documented allergy checking, and extra safeguards around medicines known to carry higher risk.

The Commission identifies groups of high-risk medicines that warrant additional care, including insulin, anticoagulants, opioids and anti-infectives. If you take one of these, it is worth knowing that it sits in a category clinicians treat with particular caution — and worth making sure it is on your list in every setting.

What you can do, at each point

At the GP

Bring the written list, including medicines prescribed by other clinicians.
Mention over-the-counter medicines and supplements — interactions are real.
State allergies with the reaction: “penicillin, anaphylaxis” carries far more than “penicillin”.
Ask what the new medicine is for, how long for, and what to watch for.

At the pharmacy

Use one pharmacy where you can — they see the whole picture.
Ask a question if a tablet looks different from last time. Manufacturers change, but so do dispensing errors.
Ask about a Home Medicines Review if you take several medicines.
Read the label before you leave, not in the car park.

In hospital

Hand over your list on admission rather than reciting it.
It is reasonable to ask what a medicine is before taking it, and staff would rather be asked.
Make sure your allergy is recorded, not just mentioned.
At discharge, ask what was added, stopped and changed.

At home

Keep one supply, not duplicates in several places.
Clear out stopped and expired medicines — return them to any pharmacy.
Never take someone else’s medicine, even for the same condition.
Build a routine that does not depend on memory. See how to manage your medication.

Most medication errors start with something nobody knew.

A MedibandPlus profile keeps your medications and allergies readable — including in an emergency, when you cannot answer the question yourself.

See how MedibandPlus works

Part of the Mediband family. Designed in Australia since 2004.

Five questions worth asking about any new medicine

What is it for?
How and when do I take it — with food, at night, away from other medicines?
What are the common side effects, and which ones mean I should ring?
How long am I taking it for, and who reviews it?
Does it interact with anything else on my list?

Asking these is not doubting your clinician. It is closing the exact information gaps where errors live.

If you manage someone else’s medicines

Managing medicines for a parent, partner or child adds a second failure point: two people can each believe the other gave the dose. That is one of the commonest causes of accidental doubling, and it is entirely preventable with a shared record rather than a shared assumption.

Write the routine down so anyone stepping in follows the same one.
Tick doses off on a chart or a packed pack, so the question never has to be answered from memory.
Keep one supply in one place, not duplicates across two households.
Carry their list with you, because you may be the one at the hospital answering questions.

The gap nobody can close for you

All of the above assumes you can participate. In an emergency you may not be able to, and medications and allergies are two of the three things a responder cannot work out by looking at you — see what emergency responders look for. Something worn that points to a current record is the only version of this that survives you being unconscious.

If an error happens

Say so immediately if you notice at the time.
For a suspected overdose, ring the Poisons Information Centre on 13 11 26. Call Triple Zero (000) if the person is drowsy, having trouble breathing, fitting or unresponsive.
Write down what happened, with dates, names and what you were told.
Ask for an explanation from the treating team, then the patient liaison service if needed.
Each state and territory has a health complaints body if it goes further.

Related reading: medical errors in Australia, staying safe in an emergency with a chronic condition, and what to include in medical records. To keep your list readable when you cannot speak, create your emergency profile.

FAQs

What is a medication error?

Any preventable event that leads to, or could lead to, inappropriate use or harm. It includes the wrong medicine, dose, strength or form, a missed or mistimed dose, a medicine given despite a documented allergy, two medicines that interact, a medicine continued long after it should have stopped, and instructions that were misread.

How common are medication errors in Australia?

Research reviewing Australian data from 1988 to 2021 estimated at least 250,000 hospital admissions a year are medication related, at a cost of roughly $1.4 billion, with around two-thirds considered potentially preventable. Medicine safety is a national priority area for the Australian Commission on Safety and Quality in Health Care.

When are medication errors most likely?

At transitions: a new prescription, a hospital admission, a discharge, or seeing a new clinician. Lists change at those moments and are easily lost. Errors also occur at prescribing when the history is incomplete, at dispensing with similar names or packaging, at administration, and at monitoring when nobody reviews whether a medicine is still needed.

What is medicine reconciliation?

It is the formal process of comparing the medicines someone was taking before admission with what is prescribed now, so that nothing is unintentionally added, omitted or changed. It is part of the Medication Safety Standard that Australian hospitals work to, and it works far better when you hand over an accurate written list.

What should I ask about a new medicine?

What it is for, how and when to take it, the common side effects and which ones mean you should ring, how long you are taking it for and who reviews it, and whether it interacts with anything else on your list. Asking is not doubting your clinician; it closes the information gaps where errors live.

Which medicines are considered high risk?

The Australian Commission on Safety and Quality in Health Care identifies groups warranting additional care, including insulin, anticoagulants, opioids and anti-infectives. If you take one of these it is worth knowing clinicians treat that category with particular caution, and worth making sure it appears on your list in every setting.

What should I do if a medication error happens?

Say so immediately if you notice at the time. For a suspected overdose ring the Poisons Information Centre on 13 11 26, or call Triple Zero (000) if the person is drowsy, having trouble breathing, having a seizure or is unresponsive. Write down what happened with dates and names, ask the treating team for an explanation, and escalate to patient liaison or your state health complaints body if needed.

Sources

ACSQHC — Medication Safety Standard — what hospitals are required to do.
ACSQHC — Medication safety — medication-related harm as a national priority.
healthdirect — Medicines — using medicines safely and keeping a list.
NPS MedicineWise — for consumers — independent medicines information.
Home Medicines Review — the government-funded pharmacist review service.

Disclaimer: This article is general information about medication safety, not medical advice, and it is not guidance on any specific medicine. Never start, stop or change a dose without speaking to your GP or pharmacist. For a suspected overdose or poisoning, call the Poisons Information Centre on 13 11 26. In an emergency, always call Triple Zero (000). For non-urgent health advice, call healthdirect on 1800 022 222 (NURSE-ON-CALL 1300 60 60 24 in Victoria, 13 HEALTH 13 43 25 84 in Queensland).