Three national quality use of medicines (QUM) publications have recently been updated. These publications are the:

These updated publications build upon previous versions and aim to improve the quality and safety of medication management in Australia. These guiding principles align with the National Medicines Policy with a focus on person-centred care in aged care facilities, the community and at transitions of care.

The Guiding principles to achieve continuity in medication management is particularly relevant to the hospital environment and aims to promote the quality use of medicines during transitions of care.

Transitions of care are situations where all or part of a patient’s care is transferred between healthcare locations, providers, or levels of care, including:

  • Between healthcare providers (e.g. clinical handover in a hospital where one nurse hands over the responsibility for a patient’s health care to another nurse);
  • Between levels of care in the same location (e.g. transfer of a patient from an emergency department to a ward in a hospital);
  • Between healthcare locations or settings (e.g. transfer of care from ambulance service to an acute care service);
  • When care needs change (e.g. transfer from an acute care service to an aged care home);
  • When an individual’s preferences change (e.g. transfer of a patient from an oncology ward to a palliative care service due to end-of-life care preferences);
  • When access to services changes (e.g. transfer of ongoing care from paediatric services to adult services); and
  • Between levels of healthcare (e.g. an individual is discharged from a mental health inpatient facility back to the care of their GP).

These transitions of care form an integral part of the patient experience in the healthcare system. However, care transitions are also recognised as high-risk situations for patient safety. Studies demonstrate that more than 50% of medication errors occur at transitions of care, although this figure may be higher in some settings.

The Australian Commission on Safety and Quality in Healthcare (the Commission) highlights four transition points as being particularly prone to error. These are admission to the hospital, transfer from the emergency department (i.e. to a ward, intensive care, home), transfer from the intensive care unit to the ward, and transfer from the hospital (i.e. to home, aged care home, or another hospital).

The risk of medication errors and the potential for harm from those errors will vary depending on the patient. An individual’s risk of experiencing a medication error increases as the number of medicines they take increases. Patients at higher risk of harm from these errors include those taking high-risk medications (e.g. opioids, chemotherapy, anticoagulants) and patients with comorbidities (e.g. renal impairment).

Potential consequences of these errors include increased adverse effects, preventable readmissions, and increased morbidity and mortality. There is also likely to be significant dissatisfaction for both patients and healthcare providers alike.

Due to the significant nature of these potential outcomes, improving medication safety at transitions of care was identified as a key priority of the Medication without harm – WHO Global Patient Safety Challenge – Australia’s response. The Guiding principles to achieve continuity in medication management address this through its ten principles. Guiding principles one to four set the overarching system requirements, while the remaining principles outline specific activities.

These guiding principles, based on Commonwealth of Australia (Department of Health and Aged Care) material, are shown below.

Guiding Principle 1: Clinical governance and leadership

“Leaders of healthcare services have responsibilities in ensuring the safe and quality use of medicines and in ensuring the ongoing continuity of medication management.”

Guiding Principle 2: Responsibility for medication management

“Providers of healthcare services, managers and healthcare professionals have a responsibility to participate in all aspects of medication management in partnership with the individual receiving care, their carer and/or family.”

Guiding Principle 3: Accountability for medication management

“Providers of healthcare services, managers and healthcare professionals are jointly and individually accountable for making sure that activities to support the continuity of medication management are implemented.”

Guiding Principle 4: Safety and quality systems

“Safety and quality systems are integrated within governance processes to enable providers of healthcare services and healthcare professionals to actively manage and improve the safety and quality of health care for and with individuals receiving care.”

Guiding Principle 5: Medication reconciliation

“Accurate and complete medication reconciliation should be performed at the time of presentation or admission, or as early as possible in the episode of care. Medication reconciliation needs to be performed at all transitions of care.”

Guiding Principle 6: Review of current medicines

“Throughout each episode of care, the safe and quality use of current medicines needs to be assessed and reviewed in partnership with the individual receiving care.”

Guiding Principle 7: Medication management plan

“A medication management plan needs to:

  • Be developed by healthcare professionals, in collaboration with the individual receiving care, to develop strategies to manage the individual’s medications medicines
  • Form an integral part of care planning for the individual receiving care
  • Be reviewed during the episode of care and before transition of care.”

Guiding Principle 8: Sharing decision-making and information about medicines with the individual receiving care

“As early as possible in the episode of care, the individual receiving care, their carers and/or family should receive sufficient information, in a form they can use and understand, to enable them to safely and effectively use all medicines in accordance with the agreed medication management plan.”

Guiding Principle 9: Collaborating and communicating medicines-related information with other healthcare professionals

“When an individual is transitioned to another episode of care, the transferring healthcare professional needs to supply comprehensive, complete and accurate information to the healthcare professional responsible for continuing the individual’s medication management in accordance with their medication management plan.”

Guiding Principle 10: Ongoing access to medicines

“The individual receiving care, their carer and/or family needs to receive sufficient supplies of medicines and information about how to obtain further supply of medicines, to enable them to fulfil or comply with their medication management plan. This should consider person-specific circumstances and equity of access.”

The complete guiding principles document is available for download here; a condensed version can be accessed here.


  1. Department of Health and Aged Care. Guiding Principles to Achieve Continuity in Medication Management. Canberra: Commonwealth of Australia; 2022.
  2. Transitions of Care: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016.
  3. Wang Y, Zhang X, Hu X, Sun X, Wang Y, Huang K, et al. Evaluation of medication risk at the transition of care: a cross-sectional study of patients from the ICU to the non-ICU setting. BMJ Open. 2022;12(4): e049695.

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