A woman who was issued the wrong acne medication by her pharmacist says the mistake has had a "huge effect" on her ability to start a family, according to a finding by the Health and Disability Commission.
A pharmacist has been found to have breached the Code of Health and Disability Services Consumers' Rights for failing to check the correct medication was dispensed.
The woman was prescribed isotretinoin for her acne on April 7, 2021, However the pharmacist incorrectly put acitretin — which is a medication used to treat skin disorders such as psoriasis — in the box marked isotretinoin.
Acitretin is not recommended for use by people planning to become pregnant and patients using the medication are required to avoid pregnancy for three years. Guideline for the medication the woman was actually prescribed, isotretinoin, recommended not becoming pregnancy until at least a month after completing the course.
The pharmacist told the Health and Disability Commission (HDC) the "dispensing error was unknown" to both her and the woman when she collected the prescription from the pharmacy. The pharmacist also advised the woman of the dangers of becoming pregnant while using isotretinoin and confirmed she was using a contraceptive.
The woman took the incorrect medication for 22 days before a pharmacy technician discovered the error when the woman returned to pick up her repeat medication.
The pharmacist then apologised to the woman and explained that she had inadvertently dispensed the wrong medication, asked whether she had any side effects and apologised.
The woman told HDC: "The pharmacist came out and apologised saying they had given me the incorrect medication and it may have delayed the treatment of my acne, but never mentioned what the drug was called that I had taken or raised any concern for myself".
The woman said the dispensing error has had "a huge effect" on her and her family with the delay in starting her family.
Trauma and stress
She said she feels the error has taken away her choices, alongside causing trauma and stress to her and her partner.
Deputy Commissioner Rose Wall recommended that the pharmacist apologise to the woman and complete a written report to HDC on the learnings and effectiveness of changes implemented as a result of this case.
"In my view, a reasonable pharmacist should conduct a thorough and comprehensive review about an incorrectly dispensed medication and inform the affected patient immediately about potential adverse side effects," said Wall.
"It is clear that at the time of discovering her error, the pharmacist checked for information about the dispensed medication, but did not appreciate that there were serious side effects.
"Accordingly, I am critical that the consumer did not receive a clear explanation about the adverse side effects of the medication she had taken," she said.
Wall also recommended the pharmacy undertake an audit of its existing standard operating procedures, highlighting the importance of pharmacies having thorough operating procedures that contained step-by-step processes for dispensing and checking medications, in accordance with the Pharmacy Council Standards.
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