Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
In 2025 we analysed more than 2000 medication incidents at Metro North digital hospitals.
Instead of focusing on individual mistakes, we asked: What are these incidents revealing about how our digital systems work?
Dates: January 2025 - December 2025
Implementation sites: Metro North Health Service
Partners: N/A
Aim
Further refine a framework we call Digital Medication RiskZones (grouped themes specific to digital systems that have contributed to or been associated with a medication error).
Outcomes
Of the medication incidents reviewed from 2025 to date (2132) roughly 35% were considered 'Digital'. 51 interventions were identified (Including system change requests, technical investigations, adoption material development, training improvement activities) The most commonly presented RiskZone was 'Nursing Administration Workflow'. The key learnings have been: - Robust incident data results in fast paced change governance - The most impactful medication safety changes can result from simple system design improvements - Deviations from exemplar digital workflows contribute to more than 25% of digital medication incidents – suggesting additional work is required in scenario-based training and immersion
**We are still reviewing December data but will have this completed by April
Background
Historically, request for system change have been based solely on end user requests, and or specialist group campaigns. We wanted to develop a process that highlighted our key risk areas so that we could improve our systems to compensate for these failings and hopefully reduce medication error.
Methods
We collated medication incidents from 3 live hospital sites. They were reviewed by a panel of three clinicians (two pharmacists, one registered nurse) for: - Digital contributer (yes/no) - RiskZone correlation (Nursing Administration Workflow, Prescriber System Awareness, Pharmacy Workflow, Transfer of Care, Hybrid Medication Management, System Design) - Associated action (System Change Request, Liaising with support team, development of communications or training update) If a deeper dive into the incident was required it would be assigned to one of the panel and brought back for discussion and agreement.
Monthly, quarterly and yearly reports were developed for site representatives and presentation at Standard 4 committees. Results were also shared with digital support teams and training teams.
Discussion
Lessons Learnt/Limitations:
- We refined our process of review, by assigning incidents that required a more detailed investigation to an individual panel member who would bring it back to the whole panel for review and discussion
- We coordinated access to RiskMan data via safety and quality teams at each site. This meant that we received the data for each site in different formats. We have since been granted RiskMan access and can streamline our excel format and process the data in a more routine way.
- This process could be adopted by any site with clinical informatics team. We have focused on medication errors because of our ability to obtain data from ieMR, Pyxis and Pharmacy Robot, but it could be adopted for any type of clinical incident.
References
N/A
Key contact
Claire Hosie
Specialist Pharmacist
Digital Health, Digital Metro North