Last updated 14/04/2014

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

Filling medicine bottleMedication 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 email info@hqsc.govt.nz

Current Alerts
Alerts under development
Transdermal patch alert - December 2013 Medicines safety in renal impairment
Error-prone abbreviations, symbols and dose designations NOT TO USE - Alert 4, October 2012 Prescribing by weight in children
Colchicine Alert 8 - June 2009 Metoprolol oral administration 
Caffeine citrate oral solution Alert 13 - October 2011  
Dabigatran Alert 11 - July 2011  
Diltiazem Alert 3 - December 2005  
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  
Morphine Alert 7 - October 2008  
Oral methotrexate Alert 14 - December 2011  
Potassium chloride concentrated injection Alert 1 - revised July 2008  
Warfarin Alert 2 - November 2004  
   
ADDITIONAL ADVICE
 
Colour coded wristbands  
INNs and BANs  
IT chemotherapy and IV vinca alkaloids - September 2007  
Position statement - bar coding  
Position statement - intravenous infusion practice  
   

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