NZ Herald
  • Home
  • Latest news
  • Video
  • New Zealand
  • Sport
  • World
  • Business
  • Entertainment
  • Podcasts
  • Quizzes
  • Opinion
  • Lifestyle
  • Travel
  • Viva
  • Weather forecasts

Subscriptions

  • Herald Premium
  • Viva Premium
  • The Listener
  • BusinessDesk

Sections

  • Latest news
  • New Zealand
    • All New Zealand
    • Crime
    • Politics
    • Education
    • Open Justice
    • Scam Update
    • The Great NZ Road Trip
  • On The Up
  • World
    • All World
    • Australia
    • Asia
    • UK
    • United States
    • Middle East
    • Europe
    • Pacific
  • Business
    • All Business
    • MarketsSharesCurrencyCommoditiesStock TakesCrypto
    • Markets with Madison
    • Media Insider
    • Business analysis
    • Personal financeKiwiSaverInterest ratesTaxInvestment
    • EconomyInflationGDPOfficial cash rateEmployment
    • Small business
    • Business reportsMood of the BoardroomProject AucklandSustainable business and financeCapital markets reportAgribusiness reportInfrastructure reportDynamic business
    • Deloitte Top 200 Awards
    • CompaniesAged CareAgribusinessAirlinesBanking and financeConstructionEnergyFreight and logisticsHealthcareManufacturingMedia and MarketingRetailTelecommunicationsTourism
  • Opinion
    • All Opinion
    • Analysis
    • Editorials
    • Business analysis
    • Premium opinion
    • Letters to the editor
  • Sport
    • All Sport
    • OlympicsParalympics
    • RugbySuper RugbyNPCAll BlacksBlack FernsRugby sevensSchool rugby
    • CricketBlack CapsWhite Ferns
    • Racing
    • NetballSilver Ferns
    • LeagueWarriorsNRL
    • FootballWellington PhoenixAuckland FCAll WhitesFootball FernsEnglish Premier League
    • GolfNZ Open
    • MotorsportFormula 1
    • Boxing
    • UFC
    • BasketballNBABreakersTall BlacksTall Ferns
    • Tennis
    • Cycling
    • Athletics
    • SailingAmerica's CupSailGP
    • Rowing
  • Lifestyle
    • All Lifestyle
    • Viva - Food, fashion & beauty
    • Society Insider
    • Royals
    • Sex & relationships
    • Food & drinkRecipesRecipe collectionsRestaurant reviewsRestaurant bookings
    • Health & wellbeing
    • Fashion & beauty
    • Pets & animals
    • The Selection - Shop the trendsShop fashionShop beautyShop entertainmentShop giftsShop home & living
    • Milford's Investing Place
  • Entertainment
    • All Entertainment
    • TV
    • MoviesMovie reviews
    • MusicMusic reviews
    • BooksBook reviews
    • Culture
    • ReviewsBook reviewsMovie reviewsMusic reviewsRestaurant reviews
  • Travel
    • All Travel
    • News
    • New ZealandNorthlandAucklandWellingtonCanterburyOtago / QueenstownNelson-TasmanBest NZ beaches
    • International travelAustraliaPacific IslandsEuropeUKUSAAfricaAsia
    • Rail holidays
    • Cruise holidays
    • Ski holidays
    • Luxury travel
    • Adventure travel
  • Kāhu Māori news
  • Environment
    • All Environment
    • Our Green Future
  • Talanoa Pacific news
  • Property
    • All Property
    • Property Insider
    • Interest rates tracker
    • Residential property listings
    • Commercial property listings
  • Health
  • Technology
    • All Technology
    • AI
    • Social media
  • Rural
    • All Rural
    • Dairy farming
    • Sheep & beef farming
    • Horticulture
    • Animal health
    • Rural business
    • Rural life
    • Rural technology
    • Opinion
    • Audio & podcasts
  • Weather forecasts
    • All Weather forecasts
    • Kaitaia
    • Whangārei
    • Dargaville
    • Auckland
    • Thames
    • Tauranga
    • Hamilton
    • Whakatāne
    • Rotorua
    • Tokoroa
    • Te Kuiti
    • Taumaranui
    • Taupō
    • Gisborne
    • New Plymouth
    • Napier
    • Hastings
    • Dannevirke
    • Whanganui
    • Palmerston North
    • Levin
    • Paraparaumu
    • Masterton
    • Wellington
    • Motueka
    • Nelson
    • Blenheim
    • Westport
    • Reefton
    • Kaikōura
    • Greymouth
    • Hokitika
    • Christchurch
    • Ashburton
    • Timaru
    • Wānaka
    • Oamaru
    • Queenstown
    • Dunedin
    • Gore
    • Invercargill
  • Meet the journalists
  • Promotions & competitions
  • OneRoof property listings
  • Driven car news

Puzzles & Quizzes

  • Puzzles
    • All Puzzles
    • Sudoku
    • Code Cracker
    • Crosswords
    • Cryptic crossword
    • Wordsearch
  • Quizzes
    • All Quizzes
    • Morning quiz
    • Afternoon quiz
    • Sports quiz

Regions

  • Northland
    • All Northland
    • Far North
    • Kaitaia
    • Kerikeri
    • Kaikohe
    • Bay of Islands
    • Whangarei
    • Dargaville
    • Kaipara
    • Mangawhai
  • Auckland
  • Waikato
    • All Waikato
    • Hamilton
    • Coromandel & Hauraki
    • Matamata & Piako
    • Cambridge
    • Te Awamutu
    • Tokoroa & South Waikato
    • Taupō & Tūrangi
  • Bay of Plenty
    • All Bay of Plenty
    • Katikati
    • Tauranga
    • Mount Maunganui
    • Pāpāmoa
    • Te Puke
    • Whakatāne
  • Rotorua
  • Hawke's Bay
    • All Hawke's Bay
    • Napier
    • Hastings
    • Havelock North
    • Central Hawke's Bay
    • Wairoa
  • Taranaki
    • All Taranaki
    • Stratford
    • New Plymouth
    • Hāwera
  • Manawatū - Whanganui
    • All Manawatū - Whanganui
    • Whanganui
    • Palmerston North
    • Manawatū
    • Tararua
    • Horowhenua
  • Wellington
    • All Wellington
    • Kapiti
    • Wairarapa
    • Upper Hutt
    • Lower Hutt
  • Nelson & Tasman
    • All Nelson & Tasman
    • Motueka
    • Nelson
    • Tasman
  • Marlborough
  • West Coast
  • Canterbury
    • All Canterbury
    • Kaikōura
    • Christchurch
    • Ashburton
    • Timaru
  • Otago
    • All Otago
    • Oamaru
    • Dunedin
    • Balclutha
    • Alexandra
    • Queenstown
    • Wanaka
  • Southland
    • All Southland
    • Invercargill
    • Gore
    • Stewart Island
  • Gisborne

Media

  • Video
    • All Video
    • NZ news video
    • Business news video
    • Politics news video
    • Sport video
    • World news video
    • Lifestyle video
    • Entertainment video
    • Travel video
    • Markets with Madison
    • Kea Kids news
  • Podcasts
    • All Podcasts
    • The Front Page
    • On the Tiles
    • Ask me Anything
    • The Little Things
    • Cooking the Books
  • Cartoons
  • Photo galleries
  • Today's Paper - E-editions
  • Photo sales
  • Classifieds

NZME Network

  • Advertise with NZME
  • OneRoof
  • Driven Car Guide
  • BusinessDesk
  • Newstalk ZB
  • What the Actual
  • Sunlive
  • ZM
  • The Hits
  • Coast
  • Radio Hauraki
  • The Alternative Commentary Collective
  • Gold
  • Flava
  • iHeart Radio
  • Hokonui
  • Radio Wanaka
  • iHeartCountry New Zealand
  • Restaurant Hub
  • NZME Events

SubscribeSign In
Advertisement
Advertise with NZME.
Home / New Zealand

Saving Lives: Tiny errors that lead to medication disasters

By Martin Johnston
Reporter·NZ Herald·
18 Sep, 2012 05:30 PM4 mins to read

Subscribe to listen

Access to Herald Premium articles require a Premium subscription. Subscribe now to listen.
Already a subscriber?  Sign in here

Listening to articles is free for open-access content—explore other articles or learn more about text-to-speech.
‌
Save

    Share this article

Researchers have estimated that 150 public hospital patients die each year from medication errors. Photo / Thinkstock
Researchers have estimated that 150 public hospital patients die each year from medication errors. Photo / Thinkstock

Researchers have estimated that 150 public hospital patients die each year from medication errors. Photo / Thinkstock

DHBs work to stop scores of annual deaths from misplaced decimals or illegible scrawl.

It may seem ridiculously simple, but a preprinted decimal point on hospital drug prescription charts is saving patients from the kinds of common mistakes that can potentially kill.

Researchers have estimated that 150 public hospital patients die each year from medication errors, most of which are made in hospital although some occur beforehand.

But no one knows the real figure. District Health Boards' voluntary reports to the Health Quality and Safety Commission indicate there are only a few deaths a year.

A sample of medication errors from those reports include:

Advertisement
Advertise with NZME.
Advertisement
Advertise with NZME.

•A Northland patient was given 10 times the correct dose of insulin, leaving them unresponsive and requiring emergency resuscitation.

•A patient in Manawatu was given 50ml of methadone instead of 5ml, and had to be "intensively monitored".

•A patient in Wellington who was having a suspected heart attack was mistakenly given a double dose of anticoagulant and died.

From the brief details given, it is not clear precisely what the errors were.

Advertisement
Advertise with NZME.

Asked about the number of reported decimal-point errors, the commission said one involving a 10-fold dosage error led to a patient's death in 2009/10 and the following year two errors, but no deaths, were reported.

Another common fault in handwritten prescriptions - expected to be replaced with electronic ones at all district health boards by the end of 2014 - is illegible or misleading abbreviations.

Nearly a third of health workers who were shown a badly written hospital prescription for a commission survey misread the dosage by a factor of 1000.

It was a copy of a real prescription in which the intended dose of 4mcg was written sloppily with an abbreviation that made it look like 4mg, or possibly 7mg or 1mg or microgram.

Discover more

New Zealand

Saving lives: Life and death on our hospital front lines

16 Sep 05:30 PM
New Zealand

Our hospital death-rates

16 Sep 05:30 PM
New Zealand

Young mum's cancer fight

16 Sep 10:00 PM
New Zealand

Grieving dad wants justice

17 Sep 05:30 PM

Fortunately for the patient, the error was spotted by someone who worked out that if it was 4mg, the patient would have to swallow 8000 capsules.

"We introduced the national medication chart last year," said Marilyn Crawley, chief pharmacist for the Waitemata District Health Board's hospitals and a champion of medication safety schemes.

"All our adult acute units have it," she said. It has improved clarity."

"We've got audits showing improved compliance with prescribing clearly so it can be easily read. It has a clear decimal point and there are a small number of approved abbreviations."

The nationally standardised chart is a forerunner to electronic prescriptions and is one of the key medication safety projects overseen by the commission.

It took six years to develop and still only 15 of the 20 district health boards have adopted it.

Advertisement
Advertise with NZME.

Waitemata is one of several boards on a pilot programme for electronic medicines reconciliation - a cross-check of a patient's medication history - and in November will join another pilot, for electronic prescribing.

It already has electronic dispensing machines in almost all its inpatient areas.

Ms Crawley, who oversaw the Southern Hemisphere's largest introduction of the Pyxis dispensing machines, said electronic prescribing could save lives.

"I think it will be really important," she said.

"It will allow us to improve the quality of our prescribing in the sense that it's very much more legible and enables decision-support systems on dose ranges and interactions."

The sample prescription

Advertisement
Advertise with NZME.

See goo.gl/ZLSAM for the report.

The series

Five years of hospital death rates have been made public for the first time - in the Herald. We compare health boards, investigate where lives are being lost and the battle to save them.

This week

Monday - District health boards compared, is death rate linked to healthcare quality, and how a simple checklist helps surgeons to avoid mistakes.
Yesterday - Waitemata DHB boosts heart-care capacity. A bereaved father questions medical justice.
Today - Waikato DHB strives to understand its high death rate, medication safety, and a doctor's apology.
Tomorrow - Palliative care helps Auckland DHB's good performance. A widow fights for changes.
Friday - Obesity skews the statistics in South Auckland. Lives saved by reduction of blood infections.

Contact us

Advertisement
Advertise with NZME.

Tell us your experience of hospital care. Email Martin Johnston by clicking the link below.

Save

    Share this article

Latest from New Zealand

New Zealand

Afternoon quiz: In August 2022, what happened to author Salman Rushdie?

17 May 03:00 AM
New Zealand

'Bittersweet' departure from mouldy home for mother whose baby died at the property

17 May 03:00 AM
Politics

Andrew Little formally launches mayoralty campaign

17 May 02:30 AM

The Hire A Hubby hero turning handyman stereotypes on their head

sponsored
Advertisement
Advertise with NZME.
Recommended for you
Black Ferns meet Canada in Pacific Four clash
Black Ferns

Black Ferns meet Canada in Pacific Four clash

17 May 03:20 AM
Afternoon quiz: In August 2022, what happened to author Salman Rushdie?
New Zealand

Afternoon quiz: In August 2022, what happened to author Salman Rushdie?

17 May 03:00 AM
'Bittersweet' departure from mouldy home for mother whose baby died at the property
New Zealand

'Bittersweet' departure from mouldy home for mother whose baby died at the property

17 May 03:00 AM
'Initial stages': Israel ramps up Gaza strikes in latest offensive
World

'Initial stages': Israel ramps up Gaza strikes in latest offensive

17 May 02:57 AM
Andrew Little formally launches mayoralty campaign
Politics

Andrew Little formally launches mayoralty campaign

17 May 02:30 AM

Latest from New Zealand

Afternoon quiz: In August 2022, what happened to author Salman Rushdie?

Afternoon quiz: In August 2022, what happened to author Salman Rushdie?

17 May 03:00 AM

Test your knowledge with the Herald's afternoon quiz.

'Bittersweet' departure from mouldy home for mother whose baby died at the property

'Bittersweet' departure from mouldy home for mother whose baby died at the property

17 May 03:00 AM
Andrew Little formally launches mayoralty campaign

Andrew Little formally launches mayoralty campaign

17 May 02:30 AM
Weather onslaught: Rain, damaging gales, thunderstorms to sweep over NZ

Weather onslaught: Rain, damaging gales, thunderstorms to sweep over NZ

17 May 02:21 AM
Gold demand soars amid global turmoil
sponsored

Gold demand soars amid global turmoil

NZ Herald
  • About NZ Herald
  • Meet the journalists
  • Newsletters
  • Classifieds
  • Help & support
  • Contact us
  • House rules
  • Privacy Policy
  • Terms of use
  • Competition terms & conditions
  • Our use of AI
Subscriber Services
  • NZ Herald e-editions
  • Daily puzzles & quizzes
  • Manage your digital subscription
  • Manage your print subscription
  • Subscribe to the NZ Herald newspaper
  • Subscribe to Herald Premium
  • Gift a subscription
  • Subscriber FAQs
  • Subscription terms & conditions
  • Promotions and subscriber benefits
NZME Network
  • The New Zealand Herald
  • The Northland Age
  • The Northern Advocate
  • Waikato Herald
  • Bay of Plenty Times
  • Rotorua Daily Post
  • Hawke's Bay Today
  • Whanganui Chronicle
  • Viva
  • NZ Listener
  • What the Actual
  • Newstalk ZB
  • BusinessDesk
  • OneRoof
  • Driven CarGuide
  • iHeart Radio
  • Restaurant Hub
NZME
  • About NZME
  • NZME careers
  • Advertise with NZME
  • Digital self-service advertising
  • Book your classified ad
  • Photo sales
  • NZME Events
  • © Copyright 2025 NZME Publishing Limited
All Access. All in one subscription. From $2 per week
Subscribe now

All Access Weekly

From $2 per week
Pay just
$15.75
$2
per week ongoing
Subscribe now
BEST VALUE

All Access Annual

Pay just
$449
$49
per year ongoing
Subscribe now
Learn more
30
TOP
search by queryly Advanced Search