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Inadequate Checks By Pharmacist Results In Woman Being Given Wrong Medication

The importance of pharmacists undertaking adequate checks, and maintaining and complying with professional standards was highlighted in a decision published by Deputy Health and Disability Commissioner, Deborah James.

In her decision, Ms James found a pharmacist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code), for failing to check a medication adequately before it was given to a woman, which resulted in the wrong medication being dispensed.

A woman who was prescribed exemestane (a cancer medication), was given ezetimibe (an anti-cholesterol medication), due to a dispensing error by a pharmacist. The pharmacist did not notice the error when checking the prescription, and the dispensing technician who completed a second check, did not notice the error either. The medication was given to the woman, who took it over the next two months. The error was discovered by the woman when she noticed the pills looked different following receipt of another prescription for exemestane which was dispensed by another pharmacy.

Ms James concluded that by selecting the wrong medication, not checking the dispensed prescription adequately, and allowing an incorrect medicine to be dispensed, the pharmacist failed to adhere to the professional standards set by the Pharmacy Council of New Zealand, and breached the Code.

"It is a fundamental patient safety and quality assurance step in the dispensing process to adequately check the medication being dispensed against the prescription for accuracy," says Ms James.

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The pharmacy’s standard operating procedures require a check that the medication matches the prescription. More specifically, the drug, strength, and quantity of medication must be checked against the prescription at the following three stages: when selecting the medicine from the shelf, when placing the dispensing label on the container, and when the completed prescription is being checked.

"I consider the medication error was the result of an individual’s actions, and does not indicate organisational issues at the pharmacy," says Ms James.

Ms James did not find the pharmacy in breach of the Code, but reminded the pharmacy of the importance of maintaining and complying with up-to-date standard operating procedures.

Ms James noted that both the pharmacist and the pharmacy made changes to their processes following these events. She recommended that the pharmacy provide training for staff in relation to dispensing and checking medications, and undertake an audit of medication dispensing and checking.

Ms James also recommended that the pharmacist provide a written apology to the woman, and show evidence of completion of training in Improving Accuracy and Self Checking.


Editors notes

The full report of this case will be available on HDC’s website. Names have been removed from the report to protect privacy of the individuals involved in this case.

The Commissioner will usually name providers found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.

More information for the media and HDC’s naming policy can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

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