World Patient Safety Day — 17 September 2022

Safe medication practices vital to ensure safety and wellbeing of older people


The Aged Care Commissioner is calling for patients, families, whānau, caregivers, communities, healthcare workers, and providers to show their commitment to safe medication practices for older people.

Carolyn Cooper is making this call in support of the World Health Organization (WHO) World Patient Safety Day (WPSD) on 17 September, created to inspire countries to prioritise patient safety in their healthcare systems.

Ms Cooper says the theme for this year is medication safety.

“Older people are significant users of high-risk medications. They are particularly vulnerable in situations where the transfer of important information relating to medication is undertaken, and this is vital to ensure continuity and quality of their care as they transition through the health system.

“Medications are widely used interventions in health care, and by highlighting medication safety in this year’s theme we highlight the importance of medication management systems.

“Many medications have associated risks that need to be managed and mitigated with good medication management policy and staff training (education and awareness, and competence to administer and monitor), supported by  best practice medication management systems,” says Ms Cooper.

The World Health Organization’s call for action to KNOW, CHECK, and ASK to ensure medication safety is simple. Before giving medication, healthcare workers and providers should KNOW the medication, CHECK for the right patient, medicine, route, dose, and time, and ASK the patient if they understand.

The Ngā Paerewa Health and Disability Services Standard provides the foundation for describing best practice and fostering continuous improvement in the quality of health and disability services. It sets out the rights of people and details responsibilities of service providers for safe outcomes, including ensuring people receive medicine in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. 

Two recent decisions published by the Health and Disability Commissioner (see Editor’s notes for details) highlight the importance of accurate forward planning by providers when admitting older people, and vigilance about making sure older people get their medications in a timely way.

Ms Cooper says it is critically important that aged residential care facilities have appropriate systems in place to ensure nursing staff administer all medications correctly, and for medication errors to be identified and followed up quickly.

“Older people, especially those in an aged residential care setting, frequently present with multiple co-morbidities and complex health conditions. Often they are not in a position to advocate for themselves or alert others to issues of concern, and they are reliant on the health professionals responsible for their immediate safety and wellbeing,” says Ms Cooper.

Education and promotion of the rights of older people when they receive health and disability services, and of providers’ responsibilities, are integral to drive safety improvements and ensure safe and quality health care.

“I welcome the initiative by WHO to use World Patient Safety Day this year to promote awareness of the need for medication safety and promote safer medication use. I am asking us all in the health system to answer the call to action to KNOW, CHECK, and ASK,” says Ms Cooper.


The Aged Care Commissioner, Carolyn Cooper is available for interviews. Please call the HDC communications team on 027 432 6709 if you are interested in scheduling an interview.

Editor’s notes

Case studies on published HDC decisions 

Appropriate systems for correct staff management of critically important medications vital for patient safety

Forward planning and vigilance in medication management vital to ensure continuity and quality of care of older people

See more information about WHO World Patient Safety Day here.

See more information about Ngā Paerewa Health and Disability Services Standard here.

About HDC

  • The Health and Disability Commissioner (HDC) promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code). This includes resolving complaints in a fair and timely way.
  • The Code applies to all health and disability services in Aotearoa New Zealand.
  • All people have the right to make informed decisions and give informed consent about their treatment, and to receive an appropriate standard of care that meets their needs and upholds their dignity and mana.

For more information about HDC –

About the Aged Care Commissioner

The role

  • The Aged Care Commissioner sits under the Health and Disability Commissioner as a Deputy Commissioner, with many of the Commissioner’s functions delegated to the role.
  • While the role sits in HDC, it will complement the work of other agencies who provide a broader focus on the wellbeing of all older people, such as the Ministry of Health, HealthCERT, the Office for Seniors, the Human Rights Commission, the Retirement Commissioner, and the Ombudsman.

Aged Care Commissioner’s responsibilities

  • Ensure older people, their friends and whānau have confidence in the quality and safety of health and disability services.
  • Provide strategic oversight and leadership, and encourage cross-agency collaboration to promote systemic change and drive improvements across the entire health and disability sector and be a recognisable figure for investigating complaints.
  • Ensure aged-care services are provided in a consistent and culturally appropriate way for all New Zealanders, particularly our Māori and Pacific communities.
  • Report on emerging issues and thematic improvements in the aged-care sector and for older people using the health system.
  • Advocate for better services on behalf of older people and their whānau.
  • Support the Government’s commitment to Te Tiriti o Waitangi.