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Clinical governance and quality improvement to support medication management

Organisation-wide systems are used to support and promote safety for procuring, supplying, storing, compounding, manufacturing, prescribing, dispensing, administering and monitoring the effects of medicines.

This criterion requires organisation-wide governance, leadership and commitment to support the safe and effective use of medicines.

To meet this criterion, health service organisations are required to:

  • Apply safety and quality systems to support medication management
  • Use quality improvement systems to monitor, review and improve medication management
  • Apply principles of partnering with consumers when designing and implementing systems for medication management
  • Define and verify the scope of clinical practice for prescribing, dispensing and administering medicines for relevant clinicians
  • Train, educate and support clinicians to understand their roles and accountabilities in delivering safe and effective use of medicines.

This criterion aligns closely with the Clinical Governance Standard and the Partnering with Consumers Standard.

Meeting the Medication Safety Standard may require the organisation to introduce new processes, or modify existing processes and practices to reduce the risk of medication error. This may require local project teams to oversee, plan and coordinate assessment, implementation and evaluation.

Project teams should be multidisciplinary and include clinicians responsible for various medication management activities. Partnering with patients and carers in these processes can result in improved services and a higher level of satisfaction.1

Ongoing monitoring and evaluation of the safety, quality and performance of medication management systems are also necessary to track changes over time, ensure that systems continue to operate effectively2 and identify areas for improvement. Data from evaluation of medication management should be communicated back to clinicians. They can focus clinicians on areas that need improvement, and motivate them to change practice and take part in improvement activities.2-4 Feedback processes also contribute to a culture of transparency and accountability.


Integrating clinical governance

Applying quality improvement systems

Partnering with consumers

Medicines scope of clinical practice


  1. Crawford MJ, Rutter D, Manley C, Weaver T, Bhui K, Fulop N, et al. Systematic review of involving patients in the planning and development of health care. BMJ 2002;325(7375):1263.
  2. Flottorp SA, Jamtvedt G, Gibis B, McKee M. Using audit feedback to health professionals to improve the quality and safety of health care. Geneva: WHO; 2010 (accessed Sep 2017).
  3. National Institute for Health and Clinical Excellence (UK). How to change practice: understand, identify and overcome barriers to change. London: NICE; 2007.
  4. Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006;(2):CD000259.
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