New standardised medication charts being rolled out in all District Health Boards nationwide will reduce the number of adverse events caused by misread drug charts, says Hawke's Bay District Health Board pharmacy manager Billy Allan.
Mr Allan, who was on the project's steering group, said the ultimate aim of the newcharts was to improve patient safety by minimising the potential of them being misread.
It ensured every person involved in prescribing, dispensing, administering and reviewing medicines for adult in-patients would use the same chart throughout New Zealand.
The national chart replaced those devised by individual hospitals, with design features to improve clarity.
Mr Allan said while ultimately reducing the incidences of misread drug charts, the nationalised system would initially cause an increase of reported mistakes.
"We've been training people [in using the new charts] with best practice, so they may become more aware of what bad practice is," he said. "They'll start reporting it because we've raised [their] awareness."
Mr Allan said one of the features, a pre-printed decimal point in the dosage box, could prevent adverse events such as the death of an Auckland woman at North Shore Hospital this month. The woman died after receiving 10 times the prescribed drug dose. Other media reported the mistake may have occurred after a nurse overlooked a decimal point on the patient's medication chart.
Mr Allan warned however, the new charts were not foolproof.
"It's still a manual practice so there's potential for human error, there's potential for misreading it."
It was only the first step to improving medication processes, he said. The next step would be an electronic version, like that trialled at Dunedin Hospital, which he said was at least five years away from reaching the Bay.
This would not entirely eliminate the potential for error as it still required human input.
The "ultimate utopia" would be a barcoding system, he said.
Mr Allan said the new charts were only one avenue of reducing errors with medication. Patients could also reduce the risk by bringing their medication with them during hospital visits.
Last year the Health Quality and Safety Commission found there were 17 reported instances of medication errors across all DHBs.
