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Adverse events involving high-risk medicines can cause harm and even death, but harm can be reduced or prevented by identifying risks and changing systems and practice.

To support clinicians in this work, the Commission has developed a series of ‘one steps’ for medication safety to complete as part of the Open for better care patient safety campaign.

These resources are intended to: 

  • check some aspect of the safety system for a high-risk medicine in any area of work, whether on a ward, across a whole hospital or other care setting
  • stimulate discussion about the system and what changes could be made to reduce the risk of harm from those medicines.

Each one step focuses on different issues relevant to safety for some high-risk medicines, and can be completed by any clinician. Some resources focus on clinical audit of prescriptions and are particularly relevant to resident medical officers; others focus on guidelines and patient information, and might be particularly relevant to quality and risk.

One step from you could reduce harm

We are looking for new additions to our one step series – created by you. All one steps judged to be first class will be published here, for use by other health professionals.


Each one step submitted should:

  • be usable by an organisation where medicines are part of treatment
  • relate to a medicine deemed ‘high risk’ by your organisation or work area (it does not have to relate to the high-risk medicines the Open campaign focuses on)
  • focus on issues relevant to safety
  • include:
    • a short background piece (no more than 300 words) about why there is a need for the activity (include any relevant references, incidents, near misses, etc)
    • 4–6 questions designed to help clinicians check and review some aspect of the safety system, and stimulate discussion
    • advice for reviewing results and implementing change.

Please email your one steps to, and include the name/s of the author/s. An expert panel including Commission and independent medication safety specialists will judge each entry and the author/s will be notified. The winning one steps will be published here as soon as they are laid out by our designer.


By submitting a one step, author/s automatically agree to their one step/s being published by the Commission (author acknowledgement optional). You may submit any number of one steps.

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