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Provision of methadone treatment to wrong patient

Mental Health Commissioner Kevin Allan today released a report finding a pharmacist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to adequately check the identification of a woman before giving her methadone.

The woman went to a pharmacy for her prescribed dose of methadone. The pharmacist called out another patient’s name, but thinking she heard her own name called, the woman followed him into the consultation room where she consumed someone else’s dose of methadone. She also received further doses of the other patient’s methadone to take away.

While the error was quickly recognised and rectified, the Mental Health Commissioner found the pharmacist should have done more to check the woman’s identification before giving her the methadone.

"Methadone is a Class B controlled drug, and can cause death if the incorrect dose is dispensed. In my view, [the pharmacist] should have been more cautious given his lack of familiarity with the patients, particularly in light of the high risk of adverse effects," Mr Allan said.

Following the incident, the pharmacy manager stopped the woman’s methadone service. The manager informed the woman’s alcohol and drug caseworker but did not discuss the issue with the woman before making the decision, in accordance with the New Zealand Practice Guidelines for Opioid Substitution Treatment.

Mr Allan recommended that the Ministry of Health review these guidelines, to ensure both the Code and the Pharmacy Council’s Code of Ethics are able to be applied appropriately when a pharmacy stops services for a patient.

"Most patients who have received opioid substitution treatment have experienced stigma to some extent … I consider it essential that all patients who receive opioid substitution treatment are treated with a reasonable, non-discriminatory, non-judgemental and empathetic approach," Mr Allan said.

Mr Allan recommended that the pharmacist apologise to the woman. He also recommended that the pharmacy arrange refresher training for its staff, update its induction programme and carry out an audit on methadone dispensing and staff compliance with its standard procedures.

The full report for case 18HDC00795 is available on the HDC website.


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