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Te Pū rauemi KOWHEORI-19 COVID-19 resource hub

Support for people working in health during the COVID-19 pandemic. Find information about how you can support yourselves and others, including consumers, teams and colleagues which complements and aligns with Ministry of Health resources.

Kia āta kōwhiri Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

Medication errors occur in health care systems worldwide and it is important that we learn from them.

Medication errors are defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional or patient. Medication errors may be related to professional practice, drug products, procedures or systems. When a medication related error occurs, whether patient harm results or not, the error should be investigated and changes made to prevent similar mistakes.

One method to prevent errors is to introduce a standardised process for responding to alert notifications. An example of this is the removal of concentrated potassium chloride ampoules from ward areas to prevent the accidental selection and injection of undiluted potassium chloride causing patients to arrest.

The alerts produced by the Commission are recommendations relating to either internationally recognised or locally identified high risk medicines or situations. Alerts are sent out directly to relevant health care providers with the latest information and advice on particular topics of concern. 

The Commission recognises the important role patients play in preventing medication-related errors and, whenever possible, includes recommendations on patient information leaflets and ways in which people can be involved in their treatment.

If you would like to receive Medication Safety Alerts please subscribe using our web form.

Current alerts
Alert #
Released / Revised

Baclofen oral liquid medication alert

Alert 19 October 2021
Thrombolysis for acute ischaemic stroke Alert 18 March 2020
Compounded Oral Liquid Formulations   April 2019
Colchicine Alert 8 June 2009
Caffeine citrate oral solution Alert 13 October 2011
Dabigatran Alert 11 July 2011
Diltiazem Alert 3 December 2005
Error-prone abbreviations, symbols and dose designations NOT TO USE Alert 4 October 2012
Heparin Alert 12 September 2011
Humalog insulin Alert 10 April 2010
Intravenous infusion practice Alert 9 December 2009
Low molecular weight heparin in renal impairment Alert 5 January 2008
Metoprolol oral administration   August 2014
Morphine Alert 7 October 2008
Oral methotrexate Alert 14 April 2012
Potassium chloride concentrated injection Alert 1 July 2008
Transdermal Patch Alert   September 2019
Warfarin Alert 2 November 2004
Colour coded wristbands    
INNs and BANs    
IT chemotherapy and IV vinca alkaloids   September 2007
Position statement - bar coding    
Position statement - intravenous infusion practice  
Last updated: 31st January, 2022