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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a pharmacist and a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the services they provided to a five-year-old boy.
The boy had a complex medical background including spastic quadriplegia (a type of cerebral palsy), and epilepsy, for which he was prescribed the anti-seizure medication vigabatrin.
A pharmacist mistakenly dispensed valaciclovir for the boy, which is an antiviral medication, instead of his prescribed medication. The boy took this medication for several weeks before being admitted to hospital. During his admission, a number of errors resulted in the boy continuing to receive the incorrect medication and dosage on five occasions.
Deputy Commissioner Kevin Allan found that the pharmacist failed to provide services in accordance with relevant standards, and did not take sufficient steps to check that she was dispensing the correct medication.
He also found that the DHB failed to provide services with reasonable care and skill to the boy. Multiple DHB staff failed to check the boy’s medication and dose adequately and to comply with DHB policy regarding the use of a patient’s own medications.
“The DHB was responsible for ensuring that [the boy] was provided with services that complied with the Code, and for having in place adequate systems to ensure that the care delivered to [the boy] was safe and appropriate,” said Mr Allan. “In my view, there were a number of deficiencies in the care provided to [the boy] that arose from systemic issues at [the hospital]. These failures meant that [the boy] received the wrong medication for several days, and was put at risk of harm.”
Mr Allan recommended that the DHB conduct an audit of staff compliance with relevant policies, and consider further changes in light of suggestions from HDC’s nursing expert advisor. The pharmacy was asked to consider amending its procedures in relation to incident management. In addition, Mr Allan recommended that the DHB, the pharmacist and the pharmacy provide written apologies to the boy’s family, which have since been provided.
The full report for case 18HDC01272 can be found on the HDC website.