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| Ethnicity | Location | Classification |
| What happened | Outcome |
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view
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Colchicine overdose
|
HP
|
|
55
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NZ Maori
|
Residential care
|
Medication
|
Colchicine
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Patient received overdose...
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Stop prescribing colchi...
|
|
|
view
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Wrong dose of dabigatran...
|
HP
|
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82
|
NZ European / Pakeha
|
Patients home
|
Medication
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Dabigatran
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Final dose of Warfarin (3mg)...
|
I would recommend development...
|
|
|
view
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Wrong strength of digoxin...
|
GP
|
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87
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NZ European / Pakeha
|
Pharmacy
|
Medication
|
|
Patient taking digoxin 62.5...
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Improved checking processes...
|
|
|
view
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Patient prescribed extra...
|
GP
|
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94
|
NZ European / Pakeha
|
Hospital
|
Medication
|
|
Patient discharged from hospital...
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Be more careful and check...
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|
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view
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Discharge prescription did...
|
P
|
|
98
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NZ European / Pakeha
|
Hospital
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Documentation
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One of patients regular medication...
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Further information on the...
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view
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Ceftriaxone diluted incorrectly...
|
GP
|
|
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NZ Maori
|
Practice
|
Medication
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ceftriaxone
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An 8 month old child presents...
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Following discussion of critical...
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view
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Renal cancer diagnosis missed...
|
GP
|
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53
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Other Asian
|
Practice
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Clinical process/procedure
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Digoxin
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More than 6/12 history of...
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Non specific elevation of...
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|
view
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Prescribed flucloxacillin...
|
-
|
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21
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NZ European / Pakeha
|
Pharmacy
|
Medication
|
Flucloxacillin
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Patient was prescribed Flucloxacillin...
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Pharmacy notified.
|
|
|
view
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Blank prescription faxed...
|
P
|
|
4
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NZ European / Pakeha
|
Practice
|
Documentation
|
Digoxin
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Reverse page of prescription...
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Print contact details on...
|
|
|
view
|
Prescribed amoxicillin despite...
|
GP
|
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25
|
NZ European / Pakeha
|
Practice
|
Medication
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amoxicillin
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Prescribed amoxicillin for...
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I wrote to patient to apologise.
There...
|
|
|
view
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Expired IUCD inserted
|
GP
|
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21
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NZ European / Pakeha
|
Practice
|
Medical device/equipment
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IUCD
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I put an IUCD in a post natal...
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I am now vigilant about checking...
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|
|
view
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'Morning after pill' prescribed...
|
P
|
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17
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NZ Maori
|
Practice
|
Medication
|
Postinor-1
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Prescriber prescribed "Postinor-1...
|
|
|
|
view
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Lung tumour failed to be...
|
GP
|
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73
|
NZ Maori
|
Practice
|
Clinical process/procedure
|
Postinor-1
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Patient was seen at After...
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This was a patient that fell...
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|
|
view
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Medicines omitted from blister...
|
GP
|
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86
|
NZ European / Pakeha
|
Pharmacy
|
Medication
|
|
Tablets were left out of...
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Pharmacy procedures to check...
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|
|
view
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Overlooked CT result, ultrasound...
|
GP
|
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57
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NZ European / Pakeha
|
Hospital
|
Clinical process/procedure
|
Postinor-1
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Event type: overlooked result...
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Action: notified Cardiothoracic...
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|
|
view
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Missed opportunity for follow-up...
|
GP
|
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70
|
Other European
|
Practice
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Clinical process/procedure
|
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Bowel cancer, preventable.
An...
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Since 1999 we have in place...
|
|
|
view
|
Systemic S. Aureus infection...
|
GP
|
|
48
|
Fijian
|
Practice
|
Clinical process/procedure
|
|
New patient to me. Patient...
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Diabetes mellitus makes people...
|
|
|
view
|
UTI untreated prior to cystoscopy,...
|
GP
|
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80
|
NZ European / Pakeha
|
Hospital
|
Clinical process/procedure
|
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Patient had check cystoscopy...
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Perhaps treat UTI prior to...
|
|
|
view
|
Incomplete prescription details...
|
P
|
|
58
|
NZ European / Pakeha
|
Pharmacy
|
Medication
|
Salazopyrin
|
Prescription for Salazopyrin...
|
Pharmacy to be more vigilant...
|
|
|
view
|
Humalog prescribed instead...
|
P
|
|
58
|
NZ Maori
|
Practice
|
Medication
|
Humalog/Humalog MIX
|
Patient was discharged from...
|
Primarily this error due...
|
|
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