The importance of pharmacists undertaking adequate
checks, and maintaining and complying with professional
standards was highlighted in a decision published by Deputy
Health and Disability Commissioner, Deborah James.
In
her decision, Ms James found a pharmacist in breach of the
Code of Health and Disability Services Consumers’ Rights
(the Code), for failing to check a medication adequately
before it was given to a woman, which resulted in the wrong
medication being dispensed.
A woman who was prescribed
exemestane (a cancer medication), was given ezetimibe (an
anti-cholesterol medication), due to a dispensing error by a
pharmacist. The pharmacist did not notice the error when
checking the prescription, and the dispensing technician who
completed a second check, did not notice the error either.
The medication was given to the woman, who took it over the
next two months. The error was discovered by the woman when
she noticed the pills looked different following receipt of
another prescription for exemestane which was dispensed by
another pharmacy.
Ms James concluded that by selecting
the wrong medication, not checking the dispensed
prescription adequately, and allowing an incorrect medicine
to be dispensed, the pharmacist failed to adhere to the
professional standards set by the Pharmacy Council of New
Zealand, and breached the Code.
“It is a fundamental
patient safety and quality assurance step in the dispensing
process to adequately check the medication being dispensed
against the prescription for accuracy,” says Ms
James.
The pharmacy’s standard operating procedures
require a check that the medication matches the
prescription. More specifically, the drug, strength, and
quantity of medication must be checked against the
prescription at the following three stages: when selecting
the medicine from the shelf, when placing the dispensing
label on the container, and when the completed prescription
is being checked.
“I consider the medication error was
the result of an individual’s actions, and does not
indicate organisational issues at the pharmacy,” says Ms
James.
Ms James did not find the pharmacy in breach of
the Code, but reminded the pharmacy of the importance of
maintaining and complying with up-to-date standard operating
procedures.
Ms James noted that both the pharmacist
and the pharmacy made changes to their processes following
these events. She recommended that the pharmacy provide
training for staff in relation to dispensing and checking
medications, and undertake an audit of medication dispensing
and checking.
Ms James also recommended that the
pharmacist provide a written apology to the woman, and show
evidence of completion of training in Improving Accuracy and
Self Checking.
Editors notes
The
full
report of this case will be available on HDC’s website.
Names have been removed from the report to protect privacy
of the individuals involved in this case.
The
Commissioner will usually name providers found in breach of
the Code, unless it would not be in the public interest, or
would unfairly compromise the privacy interests of an
individual provider or a consumer.
More information
for the media and HDC’s naming policy can be found on our
website here.
HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).
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