Incidents like patients being prescribed 10 times the intended amount of medication, re-using needles or getting another patient's medication have prompted the Health and Disability Commissioner to call for a nationwide roll-out of electronic systems.

Commissioner Anthony Hill today published a report that looks into a litany of medication errors due to human error, misread prescriptions and failure to follow proper practice from 2009 to 2016.

It was hoped the systems would help reduce the "significant harm" caused by medication errors.

"Human error happens so it is important that organisations have systems with defences built into them to prevent those errors from reaching a patient," Hill said.


"This analysis highlights an issue I often see in complaints — a failure to do the basics well; that is, a failure to read the notes, talk to the patient, ask the questions, and undertake the necessary checking procedures."

The report was an analysis of 310 complaints closed by the Health and Disability Commissioner between 2009 and 2016 where a medication error was found to have occurred.

Anthony Hill hoped new systems would help reduce the
Anthony Hill hoped new systems would help reduce the "significant harm" caused by medication errors.

Case studies cited in the commissioner's report

• A woman was mistakenly prescribed Salazopyrin instead of Pentasa which resulted in her being hospitalised with a diagnosed deranged liver function.

• A 7-year-old with cerebral palsy was prescribed baclofen, a muscle relaxant, but the pharmacy inadvertently gave them 10 times the intended amount. The child had three hospital visits that involved increased seizures, shortness of breath and deep breathing.

• A woman suffering from breast cancer was prescribed a five-year course of tamoxifen, which is used for the treatment of breast cancer. But for a three-month prescription, she was given tenoxicam which is used as an antirheumatic, anti-inflammatory, and analgesic agent.

• A resident of a community residential mental health service was given another resident's medication, antipsychotic clozapine. The report said the dose of clozapine for the man was very high for a person who had never taken the medication previously.

• A registered nurse used the same needle for two different patients and failed to inform the second patient they had been injected with the used needle. The nurse took four days of leave then returned to inform the patient's GP. Appropriate blood tests were arranged. The blood tests all returned negative.


Hill went on to say in the report that the majority of medication errors in the data were "due to a complex interplay of human and organisational factors".

"Many medication errors were slips/lapses, whereby providers made inadvertent errors often due to error-producing conditions or latent factors in the organisational environment.

"Nonetheless across the 338 examples of error and harm assessed by HDC, some common themes and lessons are evident."

The most common prescribing errors were prescribing an inappropriate medication, that being prescribed a contraindicated medication or a medication to which the consumer was allergic/had a previous adverse reaction or the wrong dose of medication.

The most common dispensing errors were dispensing the wrong medication, followed by the wrong dose.

The most common administering errors were giving the wrong dose, followed by failure to administer a medication and giving the medication to the wrong patient.

The process of medication being delivered to a patient took multiple steps, multiple providers and multiple healthcare settings.

The commissioner said the priority should be placed on completing a nationwide rollout of electronic systems including an appropriate electronic prescribing system and electronic health record.

He also recommended that "organisational leaders foster cultures that support staff to do what is required of them".

Also to ensure individuals were doing the basics well like "reading the notes, talking to the patient, asking the questions, and undertaking the necessary checking procedures".