Therapeutic errors captured by the New Zealand National Poisons Centre: a retrospective audit.

INTRODUCTION Medication errors are one important cause of harm to patients. Information about medication errors can be obtained from diverse sources, including databases administered by poisons centres as part of their routine operation. AIM The aim of this study was to describe the data regarding therapeutic errors captured by the New Zealand National Poisons Centre (NZNPC). METHODS A retrospective study of calls made to the NZNPC between 1 September 2016 and 31 August 2018 was conducted, which involved human patients and were classified as 'therapeutic error' in the NZNPC database. Variables extracted and analysed included the demographics of the individual, the substance(s) involved, and site of exposure. RESULTS During the study period, a total of 43,578 calls were received by the NZNPC, including 5708 (13%) that were classified as 'therapeutic error'. Just over half of the exposures occurred in females, 3197 (56%) and 4826 (85%) of the calls involved a single substance. All age groups were affected and 2074 (37%) of the calls were related to children aged <12 years. A residential environment (n=5568, 97%) was the site of exposure for almost all reported therapeutic errors, most commonly in the patient's own home (n=5207, 91%). DISCUSSION This study provides insights into therapeutic error-related calls to the NZNPC. Almost all errors occurred in the residential setting. Over one-third of the calls involved children. Enhanced data capture and classification methods are needed to determine the types of errors and their possible causes to better inform prevention efforts.

Enquiries to the New Zealand National Poisons Centre in 2018.

OBJECTIVE: A retrospective analysis of enquiries made to the New Zealand National Poisons Centre (NZNPC) in 2018; which includes direct contacts through telephone of caller, patient and exposure substance characteristics, and indirect contacts through the internet of page hits by New Zealand (NZ) healthcare professionals on the TOXINZ poisons information database. METHODS: All calls made to the NZNPC, and TOXINZ page hits by NZ based healthcare professionals, from 1 January to 31 December 2018 were analysed. For calls, caller location and relationship to the patient, reason and site for the exposure, patient demographics and the management advice given by NZNPC were described. Substance classes and most frequently encountered individual agents were described for both call data and web page hits to TOXINZ. RESULTS: There were 25 330 calls to the NZNPC and 39 028 TOXINZ web page hits in 2018. Most callers were members of the public (79.4%), calling from residential settings (77.2%), reporting an exposure which had occurred in a residential setting (88.2%) because of child exploratory behaviour (50.3%), and which involved a person aged 0-4 years (50.3%) who could be managed at home (74.3%). TOXINZ searches mostly involved therapeutics, especially paracetamol. CONCLUSIONS: In 2018, the NZNPC provided assessment and/or advice in 64 358 enquiries, comprising 25 330 direct contacts and 39 028 indirect contacts. The NZNPC provides specialised services regularly used by both members of the public and healthcare professionals that contributes to the clinical management of poisoned and potentially poisoned patients in NZ.

Poisoning following exposure to chemicals stored in mislabelled or unlabelled containers: a recipe for potential disaster.

AIM: To investigate poisoning exposures to chemicals that were unlabelled, mislabelled or not in their original containers in New Zealand over the last 10 years, based on calls to the New Zealand National Poisons Centre (NZNPC). METHODS: Call data from the NZNPC between 2003 and 2012 were analysed retrospectively. Parameters reviewed included patient age, route and site of exposure, product classification and recommended intervention. RESULTS: Of the 324,411 calls received between 2003 and 2012, 100,465 calls were associated with acute human exposure to chemicals. There were 757 inquiries related to human exposure to mislabelled or unlabelled chemicals consisting of 0.75% of chemical exposures. Adults were involved in 51% of incidents, children, <5 years 32%, 5-10 years 10%, and adolescents 5%. Child exploratory behaviour was responsible for 38% of calls and adult unintentional exposures 61%. Medical attention was advised in 26% of calls. CONCLUSION: Inadvertent exposure to toxic products stored in unlabelled or mislabelled containers is a problem for all age groups. Although it represents a small proportion of total calls to the NZNPC it remains a potential risk for serious poisoning. It is important that chemicals are stored securely, in their original containers, and never stored in drinking vessels.

Hypnosedative access and risk of harm.

AIM: To review PHARMAC's decision, effective 1 September 2010, to remove the 1-month restriction on funded prescription of hypnotics and anxiolytics. METHOD: We consider the evidence for an association between access to these medicines and risk of harm. RESULTS: Prescription volumes and reported harms have both increased over the last decade in New Zealand; available studies and clinical experience suggest a causal link. Preliminary data collected since PHARMAC's funding change suggest an exacerbation of the problem. CONCLUSION: The decision to relax funding restrictions on hypnosedatives is expected to increase drug-related harms in a sub-population of users. Improved pharmacovigilance could inform policy regarding these agents.