We’re publishing this alert in response to the recently released findings from the Victorian Coroner’s Court about medication errors resulting in the deaths of 3 aged care residents. These deaths happened in different services between August 2024 and September 2025.
The coroner’s investigation identified serious concerns when the residents were administered medicine intended for another person, with tragic consequences. The coroner concluded that the medication errors could have been prevented.
The 3 incidents had similar contributing factors. These were that staff:
- did not follow the 6 rights of safe medication administration checks
- were unfamiliar with the service
- were distracted during medicine administration
- did not recognise psychotropic medications (medicines that affect the mind, emotions and behaviour) as ‘high-risk’ medicine
- did not escalate the incident urgently once the error had been detected.
In one incident, delays in communication from the provider with the family added to their distress.
Provider obligations
Under the Aged Care Act 2024, registered providers (providers) have a duty to:
- provide care that doesn’t harm the older person’s health and safety
- understand potential harms
- have processes in place to prevent harm.
Providers also have obligations under the Aged Care Quality Standards to make sure medicines are managed safely, effectively and in partnership with the older person.
For example, Standard 5: Clinical care includes Outcome 5.3: Safe and quality use of medicines. It requires you to make sure that:
- before giving medicine to an older person, you confirm it has been prescribed for them
- you give, monitor and review medicines safely and appropriately.
Outcome 5.3 includes these actions:
- 5.3.4 The provider implements processes to identify, monitor and mitigate risks to the older person associated with the use of high-risk medicines, including reducing the inappropriate use of psychotropic medicines.
- 5.3.6 The provider regularly reviews and improves the effectiveness of the system for the safe and quality use of medicines.
You also need to make sure your workers have the right skills, qualifications and experience to deliver aged care. This includes providing the training and supervision workers need to effectively perform their roles.
You also have obligations to practice open disclosure. This means that when things go wrong, you talk about it openly with the older person, their supporters and workers.
What the Commission expects
We expect you to:
- respond immediately to concerns about administering medicines
- report incidents
- understand risks for frail older people
- train and support workers
- have processes, systems and supports to prevent harm
- use the electronic National Residential Medication Chart (eNRMC) securely.
Respond immediately
When you think a worker could have made an error in administering medication, you should immediately:
- make sure the older person is safe
- confirm who is, or could be, affected
- confirm which medicines were given, when and in what doses
- check if the incorrectly administered medicine are high risk medications
- check if the medicine could cause allergy or intolerance to the older person
- activate your incident management system and processes.
When medications have been administered to the wrong person or taken by mistake, you must seek immediate medical review in all circumstances.
You can contact the Poisons Information Centre 24 hours a day, 7 days a week from anywhere in Australia on 131 126 – to assist in guiding the initial response to a medication administration error while awaiting a medical review.
Report incidents
You need to report the incident to us when:
- it caused, or could have caused, harm to an older person
- it meets the reporting requirements for reportable incidents.
You should report the incident through the Serious Incident Response Scheme (SIRS) portal in accordance with your reporting obligations.
You should also consider notifying:
- the Australian Health Practitioner Regulation Agency (Ahpra)
- the coroner – if the medication administration error has resulted in an unexpected or preventable death.
You also need to use open disclosure, record the incident and respond to it in line with your incident management obligations.
Understand risks to frail older people
Many older people living in aged care are frail. Frail older people are highly sensitive to the negative side effects of medicines. This risk increases when older people take multiple medications and/or are prescribed high-risk medicine. The coroner’s findings also show how administering high-risk medications to an older person who has not previously taken these medications can very quickly become catastrophic.
Train and support your workforce
To meet your obligations, you need to provide appropriate training, support, systems and processes to all workers (including agency staff) who administer medications.
You must make sure workers:
- follow the 6 rights of safe medication administration
- know when and how to escalate medication administration concerns. Please refer to the above paragraph titled Respond immediately for guidance.
Have processes, systems and supports to prevent harm
High-risk medicines
You should work with your medication advisory committee, pharmacists and prescribers to:
- identify high-risk medicines (including psychotropic medicines)
- carefully supervise these medicines to identify, monitor and mitigate (reduce) risks to older people
- keep a psychotropic register
- regularly review psychotropic medicines, including reducing inappropriate use.
You should facilitate access to a pharmacist to:
- support regular and as required medicine reviews for the older person
- help with clinical oversight of high-risk medicines
You should also review systems that support safe and quality use of high-risk medicines - in particular Schedule 8 medications such as opioids and benzodiazepines
- This includes ensuring that only staff qualified to administer Schedule 8 medication, in your jurisdiction, are able to do so.
- Providers should also note that The Guiding Principles for Medication Management in Residential Aged Care Facilities recommend packing Schedule 8 medication separately from other medicines in dose administration aids. This helps you identify high-risk Schedule 8 medications and comply with S8 medication security requirements.
Before giving medicines
You need to:
- support workers to identify each medicine before they give it to an older person
- support workers to confirm the resident’s identity before giving them medicine, for example by checking a recent photograph
- think about only assigning workers who are familiar with your residents and service to give medicines
- understand how and when the older person prefers to receive their medicines
- give older people an opportunity to confirm their medicines are correct before they have them.
While giving medicines
You need to support workers who administer medications, so they are not distracted during medication rounds. You can do this by:
- thinking of medication administration as a protected task
- clearly identifying who can give medicines
- having enough workers so they can give residents their medicines one at a time
- making sure workers are not giving medicines in busy, crowded areas
- asking workers to give medicines in private, in the older person’s room.
Use eNRMC securely
You must make sure that:
- only workers who are qualified to administer medicines have authorised access to the medication administration function of the eNRMC
- workers close the medication administration function at the end of each medication round
- you work with your eNRMC provider to identify ways the eNRMC can support workers to prevent medication administration errors. (This could include the use of an alert in the eNRMC to highlight high-risk medicines, such as Schedule 8 medicines.)