Reducing medication errors a priority

13 May 2011 | Medication Safety

Medication errors are an ongoing and potentially serious cause of harm, says Commission Chief Executive Dr Janice Wilson.

“As a result of medication errors, some patients will be harmed, have to spend extra time in hospital, and need additional medication or procedures.

“While we cannot go back in time and prevent particular events, we can – and must – learn from them and reduce the likelihood of this kind of avoidable harm in the future.”

She says New Zealand has an excellent health system by international standards and the vast majority of patients are treated safely and effectively.  However, for a small number of people, preventable incidents occur.

“Learning from these incidents is essential if we are to continually improve the safety and quality of care provided by our hospital services.”

Commission Board member and intensive care specialist at Middlemore Hospital, Dr David Galler, says District Health Boards (DHBs) throughout the country are working hard to reduce medication errors. One example is the national medication chart for adult patients which is currently being rolled out in DHBs. The chart is a simple, inexpensive but effective way of reducing medication errors.

“The chart is expected to be in place in most public hospitals within the next seven or eight months, and will enable easy identification of signatures, clear documentation of a patient’s adverse drug reactions and allergies and the separation of regular and non regular medicines.”

Dr Galler says another effective way of reducing medication errors is through the use of a formal medicine reconciliation process.

“The process ensures patient medicines are checked at critical handover times, such as when patients are admitted to or discharged from hospital.

“The clinicians responsible for the patient’s treatment reconcile the medicines prescribed with the medicines listed as being taken by the patient, using a second source of information as confirmation, in order to detect discrepancies which require follow up.”

An electronic prescribing service is also being trialled in the community, which will improve patient safety by making prescriptions more accurate; by reducing manual data entry and therefore transcription errors; and by the ability to send status updates to the prescriber if requested, for example notifying a doctor when a prescription has been picked up.

Hospital admissions can be reduced because prescribers and pharmacists will be able to better support patient adherence to their medication plans.

For further information contact Liz Price, Health Quality & Safety Commission Communications Advisor, 0276 957 744, 04 527 3290


  • In the 2009/2010 year, DHBs treated and discharged almost a million people.
  • An annual summary of the serious and sentinel events that have occurred in our hospitals is released each year. The 2009/2010 report showed that 17 serious medication errors were reported. This is likely to be the tip of the iceberg – estimates vary, but somewhere between 2 and 13 percent of patients admitted to hospital are estimated to have an adverse drug reaction.
  • DHBs that have introduced the national medication chart are Bay of Plenty, Lakes, MidCentral, Nelson Marlborough and West Coast, and three others will introduce the chart by the end of May.
  • Fifteen DHBs are in varying stages of implementing medicines reconciliation, and the other five DHBs (Bay of Plenty, Lakes, Hutt Valley, Canterbury and Southern) are in the planning stages and will have implemented the programme by January 2012
  • International studies show 10 to 15 percent of hospital admissions can be associated with an adverse event – although about half of the adverse events occurred prior to admission, in settings such as GP clinics and private hospitals.  Many of the events are known complications of treatment and are not preventable with current knowledge.  A very small number are serious and potentially preventable.
  • Modern health care is complex, with powerful drugs and many highly trained professionals involved in treatment that can achieve astonishing results.  With all of this comes the increased risk of human error, which is why we include sophisticated systems for checking safety.  Considering the large numbers of patients treated successfully every day, it is rare for an incident to happen – or nearly happen. 
  • For more information about serious and sentinel events, see the Health Quality & Safety Commission website.
  • For future updates on community ePrescribing, see the National Health IT Board website.

Last updated 29/02/2012