Quality use of medicines in SMHS

Medication incidents

A female pharmacist selects medication from shelvesThe use of medications is one of the most common therapeutic interventions in Australian healthcare. In a hospital setting, this is a complex process, with the delivery of each dose of medicine involving as many as 30 steps and a number of different healthcare staff. Since medication administration is such a common care intervention, it is associated with a higher incidence of errors and adverse events than other healthcare interventions.

The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and SMHS hospitals have adopted these strategies. Two examples of these strategies include the:

  • National Inpatient Medication Chart, which standardises the documentation on how medicines are prescribed and ordered
  • User-Applied Labelling of Injectable Medicines, which assists in preventing medication errors related to the wrong route, dose or medication being administered.

Read more about clinical incident management at SMHS and the Severity Assessment Code (SAC) categories


See how we measure up

The graph below shows the percentage of medication clinical incidents and their confirmed severity assessment codes (SACs) across the SMHS hospitals.

Figure 1: Percentage of medication clinical incidents by confirmed Severity Assessment Code (SAC) January 2016 – December 2018

Bar graph demonstrates that the highest percentage of clinical incidents involving medications were SAC3s and resulted in an outcome of no or minor harm to the patients involved, i.e. an average of 93.6 per cent from January 2016 to December 2018.


What do these figures show?
  • Figure 51 demonstrates that the highest percentage of clinical incidents involving medications resulted in an outcome of no or minor harm to the patients involved, with SAC3s representing an average of 93.6 per cent of these clinical incidents from January 2016 to December 2018.
  • This graph also shows that the outcome of no or minor harm (SAC3) has increased by 4 per cent over the same time period, whilst clinical incidents resulting in actual or potential moderate harm has decreased from 7.8 per cent to 4.9 per cent. Additionally, SAC1 medication-related clinical incidents remain at very low percentages and have decreased from 0.4 per cent (n=8) to 0.3 per cent (n=6) between 2017 and 2018.
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South Metropolitan Health Service