The medications we already know are risky. So why are they still causing harm?

For a sector that has spent years strengthening its clinical governance, refining compliance frameworks and responding to reform, aged care still carries a quiet, persistent risk that rarely commands the same attention. Medication-related harm remains one of the most common and preventable causes of hospitalisation among older Australians, yet it continues to sit in the background, largely unchanged.

New research from Monash University does not reveal an emerging threat or a previously unknown category of risk. Instead, it does something far more confronting. It brings clarity and structure to a problem the sector has long understood but never fully addressed in practice.

Published in the Australasian Journal on Ageing, the study establishes the first national consensus list of high-risk medications tailored specifically to Australian residential aged care. Alongside this, researchers have introduced the OZ-ABCD mnemonic, a simple framework designed to help clinicians and care staff consistently identify and manage medications that carry a heightened risk of harm.

The simplicity is deliberate. Because the challenge has never been awareness. It has been consistency.

A risk hiding in plain sight

Medication-related harm in aged care is not driven by rare or unusual drugs. It is most often linked to medications that are widely prescribed and deeply embedded in everyday care. Polypharmacy, frailty, cognitive decline and multiple chronic conditions combine to create a clinical environment where even routine medications can have serious consequences if not carefully monitored.

Existing high-risk medication lists have historically been developed with acute care settings in mind, where clinical oversight is more immediate and continuous. Residential aged care operates differently. Care is distributed across teams, monitoring is less intensive, and responsibility is shared between providers, general practitioners and pharmacists.

What has been missing is a framework that reflects that reality.

Dr Amanda Cross, lead author and senior research fellow at Monash, describes the OZ-ABCD tool as filling a critical gap in aged care safety resources. It brings together five key categories of medications that require heightened attention:

• Opioids
• Z-drugs and benzodiazepines
• Antipsychotics and lithium
• Blood thinners
• Chemotherapeutic agents and methotrexate
• Diabetes medications with a high risk of hypoglycaemia

There is nothing unfamiliar in that list. And that is precisely the point.

When familiarity dulls risk

One of the sector’s greatest challenges is not identifying high-risk medications, but maintaining a consistent level of vigilance once those medications become part of routine care.

Sedatives may be introduced to manage distress or behavioural symptoms, then remain in place longer than intended. Antipsychotics are often continued without regular reassessment. Blood thinners may not be adjusted as a resident’s condition changes, and diabetes medications can become misaligned with fluctuating appetite and weight.

Individually, these decisions can be clinically justified. Over time, however, they accumulate into systemic risk.

The OZ-ABCD framework forces a subtle but important shift in thinking. It reframes these medications not as standard treatments, but as inherently high-risk interventions that require ongoing, active management.

Bridging the gap between policy and practice

Regulatory expectations are already clear. Providers are required to have systems in place to identify and mitigate medication-related risks. Yet the effectiveness of those systems often depends on how well they translate into daily practice.

Clinical governance frameworks tend to focus on structure and documentation, while medication safety plays out in the realities of staffing, communication and time pressures. In that environment, even well-designed processes can become inconsistent.

What the sector has lacked is a shared, practical language that can be applied across disciplines. A way to ensure that nurses, pharmacists, GPs and care staff are aligned in how they identify and respond to risk.

This is where the OZ-ABCD tool has real potential. Its value lies not in complexity, but in its ability to be embedded into everyday workflows, from handovers and care planning to medication reviews and staff education.

A tool is only the starting point

There is a familiar pattern in aged care when new frameworks are introduced. They are adopted, integrated into policy documents and referenced in training, but their impact on day-to-day practice is often uneven.

The introduction of OZ-ABCD presents a different kind of opportunity. Not simply to add another tool, but to strengthen the way existing knowledge is applied.

Used effectively, it could support more meaningful medication reviews, encourage closer collaboration between pharmacists and care teams, and shift the focus towards proactive risk management rather than retrospective reporting.

That shift is not about compliance. It is about improving safety and, ultimately, quality of life.

The question the sector needs to answer

Aged care does not lack evidence when it comes to medication-related harm. The risks are well documented, widely understood and consistently reported.

What remains unresolved is why those risks continue to translate into preventable harm.

The OZ-ABCD tool offers a practical step forward. Whether it delivers meaningful change will depend less on the framework itself, and more on the sector’s willingness to apply what it already knows, with greater discipline and consistency.