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Letter to the editor

Editor, – Medication errors occur regularly in Australian and overseas health systems1,2,3,4, and their incidence may be increasing.5 There is therefore a need to improve medication use and to educate health professionals in the rational and safe use of medicinal drugs.3 The recent rapid development in safety and quality improvement in overseas and Australian healthcare systems has made it difficult for undergraduate courses to adapt quickly enough and incorporate appropriate content. It is also difficult for health professionals working at the coalface to keep up to date with the latest developments.

The Tasmanian Schools of Pharmacy and Medicine have produced an on-line learning resource for medication error prevention. Modules have been developed around actual clinical problems or cases involving a medication error. There are supporting electronic resources so that the modules may be used for self-directed learning, or as a basis for teacher-led discussion on medication safety issues.

There are currently six modules:

  • how to disclose errors to patients
  • patient communication skills
  • system improvement methods
  • the role of information technology in reducing error
  • intravenous therapy and error
  • high-risk medications.

Each module takes approximately one hour to complete. In addition there are topics covering incidence of medication error, causes, root cause analysis, the 'systems approach' to understanding error, and many case examples of medication error with suggestions for prevention. The site also features a full text search, extensive links to on-line medication safety information, quizzes and a discussion forum. A facility to report personal experiences of medication incidents is also available.

The web site should be of interest to hospitals and healthcare institutions, within and outside Australia. Flyers for doctors, nurses and pharmacists have been developed to introduce the first module. These are available on-line at

Professor Gregory Peterson
Professor of Pharmacy, Tasmanian School of Pharmacy

Mr James Reeve
PhD candidate, Tasmanian School of Pharmacy

Associate Professor Janet Vial
Associate Head, Tasmanian School of Medicine
University of Tasmania


  1. Kohn L, Corrigan J, Donaldson M, editors. To err is human: building a safer health system. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
  2. Wilson RM, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust 1999;170:411-5.
  3. Second National Report on Patient Safety. Improving medication safety. Canberra: Australian Council for Safety and Quality in Health Care; 2002.
  4. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med 2002;162:1897-903.
  5. Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med 1997;157:1569-76.