Dispensing of incorrect medication resulting in adverse reactions

Executive summary

1. This report concerns the care provided to a man by a pharmacy and highlights the importance of checking dispensed medication and having appropriate systems and standard operating procedures (SOPs) in place for dispensing medication.
2. In September 2018, the man visited the pharmacy to pick up his repeat medication. One of his medications was Trental 400mg. Tegretol was dispensed instead of Trental. The man consumed Tegretol for the next seven days and suffered adverse reactions as a result.

Findings summary

3. The Commissioner found the pharmacy in breach of Right 4(1) of the Code, as several systemic issues contributed to the dispensing error. The issues included the pharmacist having been appointed the sole charge pharmacist without sufficient training and support, the practice of dispensing repeat medicines off the label (which was inconsistent with the pharmacy’s SOPs), and the lack of an alert system for rarely dispensed medications. The Commissioner also made adverse comment about the pharmacist, as he failed to check the dispensed medication adequately.

Recommendations

4. The Commissioner recommended that the pharmacy apologise to the man, conduct an audit of all errors and near misses in relation to dispensing of medicines and staff compliance with the SOPs, arrange training for its staff in relation to dispensing repeat medications, and arrange further training for the pharmacist on his role as the charge pharmacist. The Commissioner also recommended that the pharmacist attend further training.

Complaint and investigation

5. The Health and Disability Commissioner (HDC) received a complaint from Mrs B about the services provided by the pharmacy to her father, Mr A, on 19 September 2018. The following issue was identified for investigation:

• Whether the pharmacy provided Mr A with an appropriate standard of care in September 2018.

Read the full decision.