Pharmacist’s Medication Dispensing Error

The Deputy Health and Disability Commissioner today released a report finding a pharmacist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for an error in the dispensing of medication to a woman.

The woman presented to the pharmacy to have a repeat prescription filled. The prescription included 30 tablets (one month’s worth) of ropinirole (a medicine used to treat Parkinson’s disease and restless leg syndrome). When the prescription for ropinirole was processed, the correct label for ropinirole was generated, but the label was incorrectly placed on a box of risperidone (an antipsychotic medication). The pharmacist did not ask another pharmacist to perform a second check of the medication.

The woman took the risperidone for approximately one month and her health was affected adversely.

Deputy Commissioner Kevin Allan found that by failing to check the medication against the prescription adequately and involve another pharmacist for a second check, the pharmacist breached the Code.

"[The pharmacist] was responsible for ensuring that she provided services of an appropriate standard to [the woman]," said Mr Allan. "[The pharmacist] failed to adhere to the pharmacy’s SOPs and the professional standards set by the Pharmacy Council of New Zealand. As a consequence of the dispensing error, [the woman’s] health was affected adversely as a result of not taking her correct medication, and taking a medication that was not indicated, for a number of weeks before she was alerted to the medication error."

Mr Allan considered that the dispensing error did not indicate broader systems or organisational issues at the pharmacy, and therefore that the pharmacy did not breach the Code. However, Mr Allan was critical that the pharmacy’s Standard Operating Procedures (SOPs) were not up-to-date to reflect its current practices.

Mr Allan recommended that the pharmacist undertake an audit of her accuracy in dispensing medication, and report back to HDC. He also recommended that the pharmacist provide an apology to the woman and commence a near-miss log, which she has done.

The pharmacy was recommended to provide evidence to HDC that it has amended its SOPs to reflect current practices. Mr Allan also recommended that the pharmacy provide a written apology to the woman, which it has done.

The full report for case 19HDC00059 is available on the HDC website.

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