New Framework Aims to Reduce Medication Errors After Hospital Discharge
05 Nov 2025
The Medication Management at Transitions of Care Stewardship Framework focuses on improving the way medications are managed during this high-risk period.
Each year, an estimated 250,000 hospital admissions are linked to medication-related issues, with more than half of these errors occurring during transitions, such as when patients are discharged. The new framework aims to reduce these errors by improving communication and coordination between hospital clinicians, general practitioners (GPs), and other healthcare providers.
The framework identifies patients who are at higher risk, including those over 65, individuals taking five or more medications, those on high-risk drugs, or patients with multiple prescribers.
Dr Phoebe Holdenson Kimura, the clinical lead behind the framework, emphasised that the initiative aims to improve consistency in how medication management is handled during hospital discharge across Australia. She explained that while some of the necessary practices are already in place, there is a need for more coordination and standardisation to ensure better outcomes for patients.
Key aspects of the framework include:
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Strong governance of medication management processes
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A multidisciplinary team to oversee and coordinate care
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Medication management activities aimed at reducing errors
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Continuous monitoring and evaluation to assess the effectiveness of the framework
Dr Holdenson Kimura highlighted that proactive communication with GPs is vital for ensuring safe transitions of care. The framework encourages hospitals to share discharge summaries with GPs before a patient is discharged. These summaries should include detailed medication information, such as any changes to the patient’s medications and the reasons behind those changes.
She also pointed out the importance of patients having an up-to-date list of their medications before going to hospital. This simple step, like providing a paper list, can significantly improve the safety of the process.
Digital solutions will also play a role in the framework’s success. Dr Holdenson Kimura stressed the importance of systems that allow seamless access to medication information for healthcare providers, and ensure prescribing and dispensing software work together effectively.
The new framework is a step towards reducing medication-related errors and improving patient safety during transitions from hospital to home. Monitoring and ongoing evaluation will be key to improving the system over time.
Source: Australian Commission on Safety and Quality in Health Care (ACSQHC)
