Woman’s Rights Breached When Pharmacist Dispenses Incorrect Medication

A woman’s rights under the Code of Health and Disability Consumers’ Rights were breached by a pharmacist when she dispensed incorrect medication, the Deputy Health and Disability Commissioner has found.

Dr Vanessa Caldwell said the pharmacist failed to provide services which complied with legal, professional, ethical and other relevant standards as a result, in a decision released today.

The case centres on the incorrect dispensation of Salazopyrin instead of Pentasa for management of the woman's gastrointestinal issues by the pharmacist. The woman took the Salazopyrin for seven weeks, assuming it was a substitute, but started feeling very unwell after four weeks. She immediately felt better when she received her correct prescription for Pentasa after returning to the pharmacy where the error was discovered.

"The Pharmacy Competence Standards state that a pharmacist must maintain a logical, safe, and disciplined dispensing procedure. In this case the pharmacist did not comply with this standard as she failed to double check that the correct medication had been dispensed," said Dr Caldwell.

She added that the same standards states that "a pharmacist should monitor the dispensing process for potential errors and act promptly to mitigate them. In this case, the pharmacist did not comply with this standard, as she was not aware of her mistake for approximately seven weeks when she was alerted to the error...."

The pharmacist agreed to a breach of Right 4(2) of the Code proposed by Dr Caldwell who said she had demonstrated a willingness to achieve a speedy resolution and make changes. She also noted there was the potential for a more restorative approach to managing the issue given the pharmacy is the woman’s long-term provider.

Dr Caldwell made an adverse comment against the pharmacy for not keeping relevant standard operating procedures up to date. However, she commended the pharmacy's manager for promptly making changes to prevent the error from happening again.

Dr Caldwell recommended the pharmacist, and pharmacy, formally apologise to the woman and for the pharmacy to rewrite its relevant dispensing standard operating procedures, and audit and evaluate the effectiveness of the new policies and processes and report back to HDC on the results and corrective actions taken.

Note:

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions : https://www.hdc.org.nz/decisions/latest-decisions/'.

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