A senior doctor prescribed a woman morphine even though she was allergic to it, which was written in her hospital notes which the doctor failed to refer to.
The unnamed doctor has been criticised by the Health and Disability Commission for prescribing the drug he should have known the patient was allergic to.
He failed to ask her or read in clinical notes that she was allergic to morphine.
On a Sunday in 2014 the 38-year-old patient went to a hospital emergency department concerned about a possible foot fracture after she had slipped in the shower.
She listed allergies, including to morphine, on a form and it was spelt out in nursing notes too.
The doctor failed to read these or discuss what he was prescribing with the patient.
The patient took the medication home and was just about to take it when her mother visited. Her mother, a nurse, asked to see the medication and immediately recognised what her daughter had been prescribed included morphine.
No harm was caused.
The Health and Disability Commissioner said the doctor assessed the patient well but failed to do other basic things.
An adviser said such errors were common in hospitals, caused by rushed behaviour in busy situations.