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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Health and Disability Commissioner Morag McDowell today released a report finding a pharmacist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for dispensing the wrong dose of methadone to a consumer and failing to follow relevant professional guidelines.
The man, aged in his sixties at the time of these events, had a medical history that included chronic obstructive pulmonary disease and previous intravenous drug use. He had been prescribed a daily dose of methadone as part of his Opioid Substitution Treatment Programme.
The man presented to the pharmacy and was waiting in line to receive his daily 11mg dose of methadone. The pharmacist finished administering a dose to a client, and then identified the client he thought would be next to step up to receive a dose. While the pharmacist had turned away to measure the correct dose for that client into a cup, the client left the room, and the man – who had been standing behind the intended client but was unseen due to his size – stepped forward and was waiting when the pharmacist returned to the counter with the dose he had just measured.
As a result, the man was inadvertently given and consumed another patient’s methadone dose of 75mg – almost seven times his usual dose. The pharmacist informed the man of the error as soon as he realised what had happened, and subsequently the man drove himself home before being taken to hospital by his family as a precaution.
Health and Disability Commissioner Morag McDowell found that the pharmacist failed to identify that the wrong client was standing in front of him, and dispensed the man another client’s methadone dose. He also allowed the man to drive home after the overdose, without advising him of the risks of doing so and the need to seek medical assistance and/or call an ambulance. Accordingly, the pharmacist failed to adhere to the professional standards set by the Ministry of Health and the Pharmacy Council of New Zealand, as well as the pharmacy’s Standard Operating Procedures (SOPs).
“The pharmacist’s actions in this case were potentially life-threatening, and contravened both the Pharmacy Council of New Zealand and Ministry of Health guidelines, as well as the pharmacy’s SOPs,” said Ms McDowell. “His dispensing on this occasion did not meet the standard of care that the man should have received.”
Ms McDowell recommended that the pharmacist arrange for an assessment through the Pharmaceutical Society of New Zealand, present an anonymised version of this case to his colleagues, and provide the man’s family with a written apology.
She also recommended that the pharmacy review and update its SOPs to reflect the changes made since these events, arrange refresher training for its staff in relation to dispensing and administering methadone, and conduct an audit on errors or near misses in relation to the dispensing of methadone and staff compliance with SOPs.
To read the full report on case 19HDC02146, visit the HDC website.