Dispensing Errors Fail Professional Standards Of Care

Deputy Health and Disability Commissioner Deborah James today released a report finding a pharmacist and pharmacy in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services in accordance with professional standards.

On two separate occasions the pharmacist mistakenly dispensed Ropin 1mg, instead of Rolin 1mg to a woman in her nineties. Ropin is used to treat Parkinson’s disease and restless leg syndrome, while Rolin is used in the treatment of advanced breast cancer in post-menopausal women.

Pharmacists must undertake comprehensive checks of medications before they are dispensed.

However, in this case, the pharmacist did not check the woman’s medication history and failed to identify the error when they checked the label against the prescription.

The error was picked up by the woman’s mother who noticed that her tablets were different to normal. Once the pharmacy became aware of the error, it did not take appropriate actions to prevent the error occurring again.

A second dispensing error involving the same medications occurred several months later.

On this occasion, the pharmacist undertook each step of the dispensing and checking process herself instead of having her work checked by another pharmacist or having a break between the dispensing and final check, which was the expected standard of care.

The pharmacist again failed to adequately review the woman’s medication history, which meant the previous error was not identified, and a flag that required a discussion with the woman and her mother before medication was handed over was also missed.

The Deputy Commissioner considered that the pharmacist failed to provide services in accordance with the relevant professional standards as set out by the Pharmacy Council of New Zealand and the pharmacy’s Standard Operating Procedure (SOP).

Deborah James was also critical of the pharmacist’s incident management following the errors.

"A pharmacy is required to ensure the provision of services that are safe and appropriate, which includes having adequate policies and guidelines in place. It also has a responsibility for ensuring that staff adhere to these policies and guidelines," said Deborah James.

"While there is individual accountability for the errors, I’m concerned that staff failed to comply with the SOPs in multiple respects, which I consider is evidence of a failure by the pharmacy to support its staff adequately in making them aware of the SOP requirements and actively encouraging and supporting staff to follow them," she said.

Deborah James recommended that the pharmacy complete an audit of staff compliance with the updated dispensing process SOPs, and provide details on what steps have been take to address any issues identified.

She also recommended the pharmacy:

-Undertake an audit of staff compliance with the updated dispensing errors SOP.

-Use an anonymised version of the report to educate their staff;

-Provide HDC with a "near misses" log and details of steps taken to address any issues identified;

-Provide evidence of staff training logs, demonstrating training in the pharmacy’s SOP;

-Amend relevant policies to include keeping written records of staff meetings/discussions and required actions following dispensing errors.

The full report for case 20HDC00036 is available on the HDC website.

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