A woman took anti-cholesterol medication, rather than cancer medication, over a two-month period after being given the wrong prescription by a pharmacist.
The woman had been prescribed exemestane but had instead received ezetimibe following a dispensing error.
The pharmacist failed to notice the error when checking the woman’s prescription, and a second check by the dispensing technician also missed the error.
The woman took the medication for two months before noticing the mix-up after comparing the pills to a correct prescription of exemestane dispensed by another pharmacy.
Deputy Health and Disability Commissioner Deborah James said in her decision, released today, that in selecting the wrong medication, failing to properly check the dispensed prescription and allowing the incorrect medication to be dispensed, the pharmacist failed to abide by the professional standards set by the Pharmacy Council of New Zealand, and therefore in breach of the Code of Health and Disability Services Consumers’ Rights.
"It is a fundamental patient safety and quality assurance step in the dispensing process to adequately check the medication being dispensed against the prescription for accuracy," James said.
While standard operating procedures at the pharmacy require the medication be matched to the correct prescription in three stages – when being selected from the shelf, before the dispensing label is placed on the container and after the completion of the prescription – James considered the error to be “the result of an individual’s actions, and does not indicate organisational issues at the pharmacy”.
While the pharmacy was not found in breach of the Code, it was reminded of the importance of maintaining and complying with up-to-date standard operating procedures.
James said both the pharmacy and the pharmacist involved has since made changes to their processes following the incident.
She recommended the pharmacy provide training to staff for dispensing and checking medications, as well as an audit of medication dispensing and checking.
The pharmacist was also recommended to provide a written apology to the woman, and show evidence of completion of training in Improving Accuracy and Self Checking.
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