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In four recent decisions, the Health and Disability Commissioner (HDC) has found pharmacists who made dispensing errors were in breach of the Code of Health and Disability Services Consumers’ Rights (the Code).

Health Minister Jonathan Coleman has released a statement this week, on the introduction of Pharmacy Accuracy Checking Technicians into New Zealand pharmacies. The Minister announced that a further 19 Pharmacy Accuracy Checking Technicians will begin training in February 2017, adding to the 18 trained and certified in 2016. The introduction of these new technician roles started in 2015, and Mr Coleman has stated that these roles have “freed up valuable time for pharmacists, allowing them to spend more time with patients.”

This announcement follows a number of recent decisions by the HDC in which pharmacists were found to have breached the Code. The HDC found that by failing to dispense the correct medications, and failing to check the selected medication adequately against the prescriptions, the pharmacists in the following decisions had failed to provide their patients with services in accordance with professional standards.

In the first decision, Ms A was travelling overseas. As she had previously had a life threatening deep vein thrombosis and bilateral pulmonary embolism, she required medication to lower the risk of blood clots forming whilst flying.

Ms A was prescribed with four injections. However, was mistakenly dispensed epoetin alfa 4000IU in place of enoxaparin sodium 4000IU. Ms A injected herself twice and travelled overseas. Ms A advised the HDC that the day after she arrived overseas, she felt ‘breathless, felt weak, dizzy and had flu like symptoms as well as a headache’. The backs of Ms A’s legs were also covered in bruises, and she was admitted to hospital.

In another decision, Mrs B was mistakenly provided with the wrong strength of medication. She received a supply of 400mg lithium carbonate tablets instead of the prescribed 250mg tablets. Mrs B felt ill after ingesting the incorrect medication and suffered from diarrhoea.

In another case of mistaken strength, Ms C visited a pharmacy to fill a prescription for a muscle relaxant and antispastic agent for her son who suffers from cerebral palsy. The pharmacy technician filled the prescription, which was checked by the pharmacist. Ms C was dispensed 10mg/ml of baclofen, ten times the strength prescribed.

As a result of the incorrect medication, Ms C’s son presented to the Emergency Department at a public hospital on three occasions with increased seizures, shortness of breath, and deep breathing with salvation.

The pharmacist breached the Code by failing to check accurately the strength of the medication being dispensed. Although the pharmacy technician was not found to have breached the Code, adverse comment was made about the failure to identify the strength of baclofen prescribed against the strength dispensed.

In the final decision, Ms D was prescribed 50mg tabs of Tramadol for pain relief following a wisdom tooth extraction. However, when her mother went to the pharmacy to fill the prescription, the pharmacist mistakenly selected Fluoxetine capsules from the shelf, rather than Tramadol capsules. The pharmacist told the HDC that she became distracted while labelling the packet so did not check the contents. She would usually have done so, as required by the pharmacy’s Standard Operating Procedures.

In this case, another pharmacist also checked the medication before it was dispensed but did not identify the error. She opened the packet, saw the strips of capsules were the same size as that of tramadol capsules, but did not remove the strips from the packet for a more thorough check.

The dispensing error was discovered by Ms D’s mother a week later. By that point, Ms D had taken up to 20 fluoxetine capsules, and took six capsules on at least one day. Both pharmacists were found to have breached the Code, and did not follow the pharmacy’s Standard Operating Procedures.

It can be observed from the decisions of the HDC that dispensing errors generally occur because of moments of inattention due to workload or customer needs, or not following standard procedure. In light of these decisions and the Minister’s announcement, it appears likely that the new technician role in pharmacies will help provide a further safeguard to ensure accurate dispensing of medication, and will also act as a prompt to improve pharmacies’ Standard Operating Procedures.

This article was authored by Megan Neill, Solicitor, and Hugo Kan, Law Graduate, in our Public Law team in the Wellington office.



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