A pharmacy has been criticised after a four-year-old boy was prescribed hay fever medication which was later found to contain traces of an anti-psychotic medication.
The names and locations involved in the incident have not been included in the report released by the Health and Disability Commisioner (HDC) today.
The boy had been prescribed liquid loratadine for hay fever by his GP in January 2020.
It was later opened and administered twice to the boy by his parents in November 2021.
Half an hour following the second dose, the boy experienced what appeared to be an allergic reaction and he was admitted to hospital.
Toxicology screening of the medication identified the presence of haloperidol — an anti-psychotic medication.
The pharmacy explained that loratadine was supplied in 120mL bottles, so to fill the boy's 200mL prescription a new bottle had to be used.
Its records show the last time it had dispensed liquid haloperidol was five days before it prepared the boy's medicine.
Upon review of stock levels against Ministry of Health dispensing records, the pharmacy was unable to find any discrepancies that would indicate a dispensing error.
"[W]e regret that we are not able to locate a definite reason for this occurrence and are at a loss as to how this event could have happened," the pharmacy told the HDC.
Medsafe conducted an unannounced inspection audit at the pharmacy on December 3, later commencing an investigation which concluded that it was "probable" a error occurred with the dispensed medication containing both haloperidol and loratadine.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell commended the pharmacy on actions taken once it became aware of the incident.
These included openly disclosing to the boy's parents that the incident had occurred and that the pharmacy was investigating it, extending an apology, and undertaking an incident notification.
However, she acknowledged that a serious incident had taken place resulting in the boy's hospitalisation.
"Having considered the events that occurred, I am, with the agreement of the pharmacy, adopting the findings of the Medsafe report."
Caldwell said she was "encouraged" by the pharmacy's response and "thorough" review of events.
"I consider it adequate that the key change made by the pharmacy was to implement a requirement for two people to check the medication during preparation and dispensing."
Several other changes were made at the pharmacy following the conclusion of the Medsafe investigation, including the acquiring of a tablet counting machine and a blister packaging machine to ensure more accurate dispensing and to reduce error rates.
The pharmacy also increased staffing levels and implemented new processes to ensure staff members are aware of any brand changes and changes to medication positioning.
It was recommended that the pharmacy undertake an audit of a random sample of 20 dispensed liquid medications that required reconstitution/compounding or transfer to a dispensing bottle, to determine whether these were checked by two people.
"The pharmacy is to report back to HDC with an audit summary and any corrective actions should aberrant findings be identified, within three months of the date of this report," Caldwell said.
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