Medication Safety and Hospital Referrals: A Report by the Health and Disability Commissioner.
Approach to Improving Safety
- Identification Errors
- Discontinuities, Gaps, and Hand-Off Problems
- Medication Errors/Preventable Adverse Drug Events
Setting of Care
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.