The evidence
Why medicines reviews matter
Medicines are the second most common cause of preventable hospital admission in Australia. The figures below are from the Pharmaceutical Society of Australia's Medicine Safety: Take Care report. Every one is sourced and checkable.
Where the harm comes from
Almost never one bad decision.
The problems that put people in hospital are rarely a prescribing error. They are combinations. Several clinicians each making a sound call, over years, without anyone seeing the whole list at once.
A cardiologist starts something. A rheumatologist adds something. The patient buys an anti-inflammatory at the supermarket. Each decision is defensible. The result is not.
That is what a home visit is for. Not to second-guess the prescribing, but to be the one place the whole list gets looked at together, including the things that never appear on it.
The combinations we look for
- The “triple whammy”: an anti-inflammatory with an ACE inhibitor or ARB and a diuretic. A well-recognised cause of acute kidney injury.
- Compounded bleeding risk: aspirin, an anti-inflammatory and an SSRI together
- Anticholinergic and sedative load, the driver behind a lot of falls and confusion in older patients
- Duplication under 2 brand names, the classic finding of a home visit, and invisible from the prescribing record
- Doses that no longer suit renal function
- Medicines nobody has revisited: long-term steroids and acid suppressants with no documented review
From our own reviews
6 things we found, and what they meant.
Real patterns from reviews we have conducted. Every identifying detail has been removed or changed. No age, no location, no date, no practice, and nothing distinctive enough to single anyone out. None of these patients is identifiable, including to themselves.
An anti-inflammatory nobody prescribed
- What we found
- A patient on an angiotensin receptor blocker and a diuretic was also taking an anti-inflammatory bought at the supermarket for knee pain. It was not on any list because it was never prescribed.
- Why it mattered
- All 3 together, the so-called triple whammy, is a well-recognised cause of acute kidney injury, particularly in older people and particularly in hot weather or during a gastro illness.
- What we suggested
- Stop the anti-inflammatory, review analgesia, and check renal function and electrolytes. The GP was unaware it was being taken.
The same weekly medicine, entered twice
- What we found
- A high-risk weekly medicine appeared twice on the same medicines list, under 2 slightly different entries.
- Why it mattered
- Weekly medicines taken daily, or counted twice, are among the small number of medication errors that reliably cause serious harm. The duplicate had been carried forward across several updates.
- What we suggested
- Remove the duplicate entry, confirm the intended weekly dose and day with the patient, and check recent bloods.
2 inhalers, 1 medicine
- What we found
- 2 reliever inhalers in the house under different brand names. The patient understood them as different medicines and used both.
- Why it mattered
- Double dosing on a short-acting bronchodilator, and a reliever count that made asthma control look worse than it was.
- What we suggested
- Consolidate to one, demonstrate technique, and reassess control on accurate usage. This is the classic finding of a home visit and is invisible from the prescribing record.
3 medicines, 1 compounding risk
- What we found
- Low-dose aspirin, a regular anti-inflammatory and an SSRI, all taken together. Each had been started separately, years apart, by different clinicians.
- Why it mattered
- Each is reasonable alone. Together they substantially raise the risk of an upper gastrointestinal bleed in an older patient, and no single prescriber had seen the combination.
- What we suggested
- Review the ongoing need for the anti-inflammatory, consider gastric protection, and confirm whether the aspirin is still indicated.
A diuretic taken at the wrong end of the day
- What we found
- A diuretic was being taken in the evening. Nobody had said when to take it, and the patient had settled into a routine.
- Why it mattered
- Predictable night-time trips to the bathroom, in a patient already flagged for falls risk. A fractured hip is the kind of outcome this produces.
- What we suggested
- Move the dose to the morning. No prescription change, no cost, and arguably the highest-value thing found that day.
Medicines nobody had revisited
- What we found
- A long-term acid suppressant and a long-term oral steroid, both continued for years with no record of anyone reviewing whether they were still needed.
- Why it mattered
- Both carry real long-term risk: fracture, infection and nutrient malabsorption. That is only justified while the indication holds.
- What we suggested
- Ask the original question again: is this still doing something? Often the answer is yes. The point is that nobody had asked.
Why the home matters
3 things you only find in the house.
What's actually in the cupboard
The stopped medicines still being taken. The old bottle with the superseded dose. The second inhaler under a different brand name. None of it is on the list.
What they actually do
How the inhaler is really used. Whether the tablet is halved. Which one gets skipped on the days it makes them dizzy, and never mentioned in a 10-minute consult.
What nobody has asked
The supermarket anti-inflammatory. The fish oil. The herbal remedy a relative recommended. People don't think of these as medicines, so they don't report them.
Sources
Where these numbers come from.
We don't quote a statistic we can't point at. If you want the underlying reports, they're all public.
| 250,000 hospitalisations · 400,000 ED presentations · at least half preventable · $1.4bn | PSA, Medicine Safety: Take Care |
| Item 900 schedule fee, eligibility and the 1 July 2027 change | MBS item 900 |
| 90-day referral validity, the 30-per-month cap and follow-up windows | PPA HMR Program Rules |
| Chronic condition management framework changes | RACGP, summary of CDM changes |
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