21 April 2024

Pharmacist dispensed incorrect medication to pregnant woman, says HDC

A pharmacist was found to have dispensed incorrect medication to a pregnant woman and later failed to provide a clear explanation about the adverse side effects of taking the incorrect medication.

The Deputy Health and Disability Commissioner Rose Wall has found the pharmacist, therefore, had breached Right 4(2) of the Code of Health and Disability Services Consumers’ Rights – the right to services of an appropriate standard of care that met all legal, professional, and ethical standards.

The mistake occurred when the woman was prescribed isotretinoin for acne – a medication which is not recommended for use by people planning to become pregnant. The pharmacist told HDC that she advised the woman of the dangers of becoming pregnant while using isotretinoin.

Pharmacist dispensed wrong medicine
Incorrect medicine was dispensed to a patient

However, the pharmacist incorrectly put acitretin (a medication used to treat skin disorders like psoriasis) in the box marked isotretinoin. Patients using acitretin are required to avoid pregnancy for three years. The woman took the incorrect medication for 22 days. The pharmacist discovered the error when the woman returned to pick up her repeat medication. 

In her decision, the Deputy Commissioner was also critical that the pharmacist failed to provide the consumer with a clear explanation about the adverse side effects of taking the incorrect medication after the dispensing error was discovered.

“In my view, a reasonable pharmacist should conduct a thorough and comprehensive review about an incorrectly dispensed medication and inform the affected patient immediately about potential adverse side effects,” said Wall.

“It is clear that at the time of discovering her error, the pharmacist checked for information about the dispensed medication, but did not appreciate that there were serious side effects. Accordingly, I am critical that the consumer did not receive a clear explanation about the adverse side effects of the medication she had taken.”

The pharmacist accepted full responsibility for her error. Ms Wall recommended she formally apologise to the consumer. 

The Deputy Commissioner also made adverse comment on the pharmacy, saying she was critical of its dispensing and checking standard operating procedures.

This is particularly important for medications that look alike, she said, adding that such medications should be highlighted on dispensary shelves to alert dispensers to the potential error of dispensing an incorrect medication.


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