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Dispensing error (14HDC01653)
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(14HDC01653, 29 October
Pharmacist ~ Pharmacy ~ Dispensing error ~ Checking ~
Standard operating procedures ~ Professional standards ~ Right
A woman was taking a regular medication called fluoxetine (a
selective serotonin reuptake inhibitor) to manage depression. She
was travelling in New Zealand and needed further fluoxetine, so she
saw a general practitioner (GP) to obtain a repeat
She had the prescription filled at a pharmacy. The pharmacist on
duty that day dispensed Duride 60mg in place of fluoxetine 20mg.
Duride is cardiac medication used to prevent angina. The pharmacy's
medication label, printed and affixed on the medication box, stated
that the contents were fluoxetine; however, the box and pill
packets were marked "Duride". The woman did not question the name
"Duride" on the box or pill packets.
The woman then started taking the Duride dispensed by the
pharmacist. During the time she was not taking fluoxetine, she
experienced an exacerbation in depression. She started seeing a
counsellor again and struggled to find a job owing to feelings of
inadequacy. Her relationship broke down and she suffered severe
migraines, felt nauseous, experienced random heart palpitations,
and was always fatigued.
The woman went to another GP for a further prescription. The GP
immediately told her that the pills she had been taking for
depression were not anti-depressants. The GP contacted the pharmacy
on the woman's behalf and alerted it to the error.
The pharmacy had relevant Standard Operating Procedures in place
at the time, but the pharmacist failed to ensure that he dispensed
the correct medication and the correct dose. It was held that the
pharmacist did not comply with professional standards and breached
The error occurred as a result of the pharmacist's individual
conduct as opposed to systemic issues at the pharmacy. Therefore,
the pharmacy was found not to have breached the Code or to be
vicariously liable for the pharmacist's breach.
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