13 June 2024

Cancer patient given anti-cholesterol medication in error by pharmacist

Failure to check a medication adequately by a pharmacist resulted in an anti-cholesterol medication being given to a woman instead of the prescribed cancer-medication.

The Deputy Health and Disability Commissioner, Deborah 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.

Inadequate checks by pharmacist
Pharmacist failed to check dispensed prescription adequately

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.

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,” she says.

The pharmacy was not found to be in breach of the Code, but the pharmacy was reminded of the importance of maintaining and complying with up-to-date standard operating procedures.

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.

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