A report released by the Health and Disability Commissioner today outlines how a four-week-old baby was accidentally given methadone in a pharmacy mix-up and was admitted to intensive care.
The pharmacy and a pharmacist, both not named, were found in breach of the Code of Health and Disability Services Consumers' Rights (the Code) by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
A report published today outlines how the baby was prescribed omeprazole oral liquid by her family doctor for colic in June 2018.
However, the pharmacy accidentally mixed-up the baby’s prescription with synthetic opiod methadone.
"The pharmacist had left an unlabelled bottle containing methadone on the dispensary bench, and a pharmacy technician inadvertently used that bottle to prepare the omeprazole prescription for the baby," the report states.
The baby's mother then gave her four-week-old what she thought was a dose of omeprazole but was actually methadone.
"The baby began breathing abnormally and became unresponsive. The baby was taken to hospital by ambulance and later treated in ICU. A urine sample confirmed that the baby had suffered a methadone overdose."
Caldwell's decision ultimately found the pharmacist at fault for the error, over the technician who mistakenly issued the methadone.
"As a registered pharmacist, he was responsible for ensuring he provided services of an appropriate standard. This includes compliance with professional standards set by the Pharmacy Council of New Zealand and the Ministry of Health."
"In failing to dispense the omeprazole in a safe and appropriate way, and by failing to check the final product, the pharmacist did not provide services to the baby in a manner consistent with professional standards and competent pharmacist practice," says Caldwell.
Caldwell was also critical of the pharmacist’s management post error. Pointing out the "inadequate" delay of 1.5 to 2 hours between discovery of the dispensing error and an attempt to contact the baby’s mother.
"I consider the ultimate responsibility for the dispensing error sat with the pharmacist. He held the responsibility to ensure the accurate dispensing of medicine, and should have double checked the dispensed medication."
The report concludes that the, "pharmacist has expressed sincere regret for this error and the pharmacy has implemented a number of changes to their operation to minimise the risk of this occurring again".
Caldwell said the baby could have died without the quick actions of its mother.
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