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Incorrect prescription for seizures

Monday 30 September 2019

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a disability service provider and a pharmacy in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care provided to a woman.

The woman lived in a community house run by the disability service provider. She suffered from seizures and was prescribed a medication by her GP to be administered to the skin behind her ear. The correct mode of administration was inside the mouth between the gum and cheek. The incorrect prescription was repeated nine times over four years by the GP practice and dispensed by the pharmacy.

When the woman suffered a seizure a caregiver located her medication however there was confusion as the medication was an injection but the packaging said it was to be applied to skin behind the ear. The caregiver made an unsuccessful attempt to clarify the instructions with a nurse before administering the medication behind the woman’s ear. The woman’s seizures continued and an ambulance was called.

Mr Allan considered that the GP should not have prescribed the medication in a manner inconsistent with accepted practice. The GP also failed to consistently complete the medication administration chart held by the disability services provider and failed to document the reasons for the change to the mode of administration of the medication or any discussion with the woman’s welfare guardian about this. For these reasons, the GP was found to have breached the Code.

With regard to the disability service, Mr Allan said he was concerned that when there was contradictory information about the way the medication was to be administered, that this wasn’t questioned by staff. He was also concerned by the manner in which medication was checked and deficiencies in the policy and procedures for safe administration of medication. Accordingly, the disability service was found in breach of the Code.

While Mr Allan accepted that this was not a ‘pharmacy error’ as the GP had deliberately instructed that the medication be applied behind the ear, he was concerned that multiple pharmacists failed to think critically and relied on previous dispensing rather than contact the GP. This reflected a pattern of behaviour of not following the pharmacy’s own standard procedures and the pharmacy was found in breach of the Code.

Mr Allan recommended that the GP, the pharmacy and the disability service provider all apologise to the woman and her family. In response to recommendations, the GP has agreed to undergo further training on safe prescribing and record keeping. Mr Allan recommended that staff at the pharmacy also undergo training, including in what to do if there is any uncertainty about a prescription. He also recommended that the disability service provider review its policies and procedures relating to administration of medication, and establish a regular review of client notes to ensure instructions are consistent and correct.

The full report for case 16HDC00163 is available on the HDC website.


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