Other Medication Safety Projects and Initiatives

Additional campaigns, projects and initiatives that support medication safety and quality improvement include:

Some medicines can cause serious harm, even death, if they are accidentally ingested by infants or children. Child-resistant packaging is designed to limit or delay access to medicines. A warning code, KIDCAP, has been added to i.Pharmacy systems in NSW. This information sheet provides pharmacy staff with information about the warning code and the provision of child resistant packaging.

Therapeutic Goods Administration (TGA) has updated some medicine ingredient names used in Australia to align with names used internationally. The four-year transition period for medicine companies to implement these changes ended on 30 April 2020. Some medicines with labels using old ingredient names may still be available on shelves and in warehouses while this stock is gradually used up. Not all medicine ingredient names were changed and some name changes are significant while others are minor.


Supporting materials including a poster and an abridged list of changing medicine names are available to assist with raising awareness of the medicine ingredient name changes.

The National Standard Medication Charts (NSMC) were developed to standardise the processes for prescribing, dispensing, administering and reconciling medicines across all health service organisations, and ensure patient information is communicated consistently between health professionals. All Australian public and private hospitals must use the NSMC.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) have developed a number of training and education materials.

Revisions to the NSW Medication Charts

In 2019, changes were made to various versions of the NSW Medication Charts to align with NSMC changes.

What charts are affected and what are the changes?

The following adult medication charts NH606206 (Regular Medication Chart with carbon); NH606207 (Regular Medication Chart no carbon); NH606208 (Adult Long Stay Medication Chart no carbon); and NH606305 (Adult Long Stay Medication Chart with carbon) have had the warfarin education record section replaced with an anticoagulation education record section

The following paediatric medication charts NH606303 (Paediatric Medication Chart no carbon); NH606304 (Paediatric Medication Chart no carbon); and NH606306 (Paediatric Long Stay Medication Chart no carbon) have had the inclusion of a dose calculation field to the telephone orders section.

What do I need to do?

Ensure you are aware of the changes and that you complete the new sections appropriately.

Contact the CEC via email or visit the ACSQHC's NSMC webpage for further information.

Quality use of medicines (QUM) involves judicious selection of treatment options (including choice between drug, non-drug and no treatment), appropriate choice of medicine when a medicine is required and safe and effective use of medicines.

The National Quality Use of Medicines Indicators are process indicators. They do not directly measure outcomes from medicines use. They do, however, focus on areas where the link between process and outcome is clearly established, so they are clinically meaningful to clinicians and their patients. They have been developed with input from doctors, pharmacists, nurses, consumers and managers around the country.

The NSW Community Pharmacy Palliative Care Initiative aimed to enhance palliative care services within NSW, through supporting the role of community pharmacy in improving medication management for people with palliative care needs.

The NSW Community Pharmacy Palliative Care Initiative was a two-year project, led by the CEC. The project involved two phases:

Phase 1 report and attachments

Phase 2: Strategic Initiatives

Further information

The process of dispensing medication is considered to be relatively accurate, however the high volume of items dispensed through pharmacies each year provides significant opportunity for patient harm. Barcode scanning has been shown to reduce the rate of pharmacy dispensing errors [1].

The implementation of barcode scanning has also been recommended by peak pharmacy bodies such as the Pharmacy Board of Australia; the Pharmaceutical Society of Australia; and the Society of Hospital Pharmacists of Australia.

The Safety and Quality Guide associated with the National Safety and Quality Health Service Standards (2017) lists the implementation of barcode scanning as a strategy to improve accuracy in medicine selection and dispensing (under criterion 4.15).

    Put Dispensing Errors Behind Bars

    The "Put Dispensing Errors Behind Bars" campaign has been developed to provide pharmacy departments with tools and resources required to raise awareness; review current workflows; and provide pharmacy staff with training so that barcode scanning is implemented in all departments state-wide.

    Barcode scanning resources for NSW Public Hospitals


    [1] Nanji, KC., Cina, J., Patel, N., Churchill, W., Gandhi, TK., Poon, EG. Overcoming Barriers to the Implementation of a Pharmacy Bar Code Scanning System for Medication Dispensing: A Case Study. Journal of the American Medical Informatics Association. 2009;16(5):645-50).

    Medicine name confusion contributes to thousands of medication errors each year [1], some causing significant patient harm [2].

    The risks associated with medicine name confusion can be reduced through the application of Tall Man Lettering. Tall Man Lettering uses a combination of lower and upper case letters to highlight the differences between look-alike medicine names, helping to make them more easily distinguishable.

    In 2015, the Hospital Pharmacy Product List (HPPL) was updated to include Tall Man Lettering. While pharmacy and nursing staff are the primary clinicians exposed to Tall Man Lettering, any staff members that may be exposed to Tall Man Lettering should be made aware of its purpose and benefits.


    [1] Phatak HM et al. Journal of the American Pharmacists Association 2005;45:616-24.
    [2] Hoffman JM, Proulx SM. Drug Safety 2003;26(7):445-52.

    Failure to recognise the correct container (for example; bags, bottles, syringes) for injectable medicines and fluids, or the correct conduit (for example; administration lines, invasive monitoring lines, catheters or burettes) can result in an administration error.

    The Australian Commission on Safety and Quality in Health Care has developed the National Standard for User-applied Labelling of Injectable Medicines, Fluids and Lines (Labelling Standard) to ensure accurate communication of injectable medicines and fluids information through standardised user-applied labelling. The Labelling Standard replaces the 2012 National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines.

    The NSW Health Policy on User-applied Labelling of Injectable Medicines, Fluids and Lines (PD2016_058) sets out the requirements for user-applied labelling in NSW Public Health Organisations and NSW Ambulance.

    It is essential that clinicians are familiar with how to use paper medication charts in the event of eMR downtimes. These resources can be used to train prescribers, nurses and pharmacists on how to use the Adult and Paediatric (paper) National Inpatient Medication Chart (NIMC).