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Terminally Ill Woman Dispensed Incorrect Amount Of Pain Medication

Deputy Health and Disability 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 making a number of errors, on different occasions, when dispensing a terminally ill woman’s pain medication.

The woman was taking the controlled drug fentanyl, a very strong pain relief medication, to manage the symptoms of her terminal illness. Her husband was her caregiver and collected the medication on her behalf.

On the first occasion, the pharmacist dispensed five fentanyl patches instead of the prescribed six. According to the prescription the woman should have received three patches initially, with a repeat of three more at a later date. The way the pharmacist dispensed the prescription resulted in the woman being supplied more than the accepted amount of 10 days’ supply at one time. It also resulted in her being deprived of the sixth patch, which would have constituted a further three days’ pain relief.

Subsequently, when presented with a prescription for five bottles of liquid fentanyl, the pharmacist only dispensed three due to concerns he had about the prescription. The pharmacist did not contact the prescribing doctor to raise these concerns, which would have been accepted practice. When dispensing a further prescription for fentanyl patches, the pharmacist supplied 14 patches to the woman’s husband which amounted to a 21 day supply of the medication. This was contrary to accepted practice and the pharmacy’s standard operating procedure at the time of the events.

Mr Allan was critical of the dispensing errors made by the pharmacist and stated that the pharmacist needed to comply with professional and legal obligations. Mr Allan noted that the pharmacist had apologised to the woman’s family and recommended that he undergo further training in relation to palliative care. He also recommended that the Pharmacy Council conduct a competency review of the pharmacist.

The full report for case 18HDC00536 is available on the HDC website.

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