Towards system-wide strategies for reducing adverse drug events

Despite the best efforts of committed health-care workers, there are many adverse drug events (ADE). A large proportion of ADE arise from system factors, either directly (e.g. poor equipment design) or indirectly (e.g. inappropriate rostering of staff). This paper represents the proceedings of a workshop focus group that deliberated on priority health-system issues identified as requiring action in order to minimise the risks of ADE. Major issues canvassed were the gathering of appropriate and useful data about ADE, the dissemination of information to professionals and consumers, and effective communication across groups of professionals, and between professionals and consumers. A number of recommendations were put forward as important first steps in addressing these issues.