13 December 2005
National strategy launched for the safe and quality use of medicines
To err may be a human trait but recent studies and serious incidents have increasingly highlighted the magnitude of
adverse events related to failures in the systems that exist in healthcare. Each year nearly 1,500 deaths coming under
the label “adverse events” occur in our hospitals – more than three times the annual road toll.
The 21 District Health Boards of New Zealand realise that the challenge is to make systematic change and improvement in
the way that care is fundamentally delivered. They recognise that humans will always be prone to risk of error and that
better designed systems and effective technology are a necessary part of the solution.
The result. The launch of New Zealand’s first coordinated national strategy that focuses on safe and quality use of
According to lead CEO, Dr Dwayne Crombie from the Waitemata District Health Board, medicine safety is an important area
to focus on by virtue of the fact that medicines are one of the most common therapeutic interventions used in the
‘We know that the level of medication errors is hugely significant. Either patients are given the wrong thing, or the
wrong amount of the right thing, or they don’t take something that’s been prescribed or they take something their
neighbour’s been trying. There are also lots of errors which occur from written orders.
“The sheer scale of medicine’s usage means that any major reduction or prevention of adverse drug events holds the
prospect of a substantially safer health system for everyone.”
One of the key objectives of the strategy was to highlight the risks and suggest changes to systems and processes used
in primary and secondary care environments for high risk medication. Eight high-risk medicines have been highlighted in
the strategy as warranting sector-wide alerts to be issued on how to improve the safe and quality use of these
Diltiazem is one such high risk medication that is commonly given to people suffering from cardiac conditions.
The Safe and Quality Use of Medicines Group (SQM), who worked on the strategy, identified serious concerns over the
prescribing of Diltiazem. Diltiazem is produced by two manufacturers in six strengths and using different formulations
(plain or fast acting, slow-release or long acting). The formulations are not interchangeable and admission and
discharge information and prescriptions have not consistently been specific about the brand, formulation or strength of
Diltiazem the patient has been prescribed.
The alert for Diltiazem is soon to be released by the SQM and will outline the nationally recommended actions to take
for all health professionals to reduce the potential risks associated with this medication.
The National Strategy also outlines a case for national leadership and coordination and sets forth an agenda on a number
of different strategies to take New Zealand toward an environment of safer and better quality use of medicines.
The DHBNZ Safe and Quality Use of Medicines Group (SQM) was established in 2003 following a clear mandate from the 21
District Health Boards to improve the national focus on the safe and quality use of medicines.
The membership of the group is multi-disciplinary with members coming from the disciplines of pharmacy, nursing,
management, public health, internal medicine, general practice and pharmacology.
The Safe and Quality Use of Medicines National Strategy (2005) produced by SQM covers medicine activities in both
primary and secondary care and has been designed to provide a national framework and co-ordination of activities to
improve medicine related outcomes.
The National Strategy and all high-risk medication alerts are available on the SQM website: www.safeuseofmedicines.co.nz