Introduction

Medication safety is a hot topic around the world but tends to focus on what professionals believe about prescribing, supply and safe administration of medicines.1 Historically, less attention has been paid to the patient or carer’s perspective, including how they take or give medicines at home. One key question that we ought to consider routinely is this: what does the patient or carer do with a medicine once they are away from the gaze of the healthcare professional? Emerging patient medication safety data from the home setting is raising concerns. For instance, in some studies it was estimated that 9 out of every 10 parents, carers or family members have administered a medicine incorrectly at some point.2 Such errors included dosage mistakes, wrong medication and wrong route of administration. We acknowledge that what health professionals deem to be ‘incorrect’ may be deliberate and reasoned by carers or patients, and this issue is beyond the scope of this article. However, legitimate concern about mistakes in using medicines is matched by an inertia within the healthcare system to identify and address such problems. More research is needed into medication administration errors in patients’ homes. Healthcare professionals may be more concerned about the administration of complex or high-risk medicines, such as oral anticancer agents, anticoagulants, insulins or biologics, and of course, it is critical that patients use these safely. However, our view is that we have neglected to check as part of our routine practice that administration of medicines is correct for lower risk or more commonly used tablets, capsules and …