Man’s Rights Breached Under The Code For Prescription Error 22HDC00897

Note: the events outlined in this report took place in 2021-2

A man’s rights under the Code of Health and Disability Services Consumers’ Rights (the Code) were breached by a supervising pharmacist, according to a report published today by Deputy Health and Disability Commissioner Deborah James.

The man’s prescription was faxed by his GP to his pharmacist and was printed by the pharmacy as four double sided pages. The final page contained a prescription for Sinemet, a medication for Parkinson’s Disease, which was intended for another patient at the same practice.

The intern pharmacist who processed the prescription noted that Sinemet was new for the man but did not identify that it was not prescribed for him. The supervising pharmacist checked the prescription and also did not identify that the medication was prescribed for another patient.

The man returned for two more repeat prescriptions of the medication over three months until he complained to his GP of dizziness and imbalance and the GP discovered that the Sinemet had been incorrectly dispensed to the man. The GP contacted the pharmacy and an internal investigation confirmed the error.

Ms James found the supervising pharmacist breached the Code for failing to provide services of an appropriate standard | tautikanga. The breach covered several failings.

First, the supervising pharmacist did not verify the patient details on each page of the prescription during the checking process.

Second, the pharmacist did not follow the Standard Operating Procedures (SOPs) for processing, dispensing and checking prescriptions. These procedures are designed to prevent this kind of error occurring and ensure patient safety.

Finally, there was no documentation of the required counselling conversation with the man about the new medication. Proper documentation is crucial to maintain a record of the care provided.

Ms James made an adverse comment about the intern pharmacist for not verifying patient details under pressure. She also made an adverse comment about the pharmacy for missed opportunities to identify the error and inadequate documentation of patient counselling.

Since these events, the pharmacy has made several changes to prevent future errors, including retraining staff, updating SOPs, and switching to ePrescriptions. In addition to these changes, Ms James made further recommendations, outlined in the report. 

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