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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 pharmacy and pharmacist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in relation to dispensing medication to a teenager.
The teenager was prescribed sumatriptan for migraines. The pharmacist mistakenly dispensed another medication, sertraline, which is used to treat depression, obsessive-compulsive disorder, panic attacks, anxiety or post-traumatic stress disorder. The error was discovered over six months later by the teenager’s school nurse.
The Deputy Commissioner considered that the pharmacist did not check the dispensed medication adequately. The pharmacy failed to undertake an adequate review of the error, missing an opportunity to identify how the error occurred and to identify actions to minimise such errors in the future.
“This report highlights the importance of pharmacists undertaking adequate checks, and of pharmacies responding appropriately when errors occur,” Mr Allan said.
The Deputy Commissioner noted that the pharmacist has made a number of changes to her practice in response to the complaint and provided HDC with a written apology. He recommended the pharmacist also provide evidence of her completion of the Improving Accuracy and Self-Checking Workbook to HDC.
Mr Allan made a number of recommendations to the pharmacy, including that it provide a formal written apology to the teenager’s mother and outline the actions it had taken to prevent such an error happening again, and arrange refresher training for its staff in relation to dispensing and checking medications and dispensing error.
He also recommended the pharmacy undertake a random audit of the dispensing and checking of medication of 20 prescriptions over a one-month period and undertake a review of any dispensing errors in the last six months.
The full report on case 20HDC00383 is available on the HDC website.