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Dispensing error at community pharmacy (06HDC12613)

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(06HDC12613, 27 February 2007)

Pharmacist ~ Pharmacy ~ Prescription ~ Dispensing error ~ Standard operating procedures ~ Reporting procedures ~ Vicarious liability ~ Rights 4(1), 4(2)

A 31-year-old woman was discharged from hospital after giving birth. The obstetric registrar hand-wrote a prescription for one 325mg ferrous sulphate tablet once a day, and one 200mg tablet of labetalol three times a day. The woman attended a pharmacy to have the prescription dispensed.

When the pharmacy technician entered the prescription on the computer, she incorrectly read the prescription, and typed "Largactil" instead of "labetalol". Concerned about the prescription because Largactil does not come in 200mg tablets, she checked the shelves and the computer system to confirm that only 100mg tablets were available, and annotated the prescription accordingly. The pharmacy technician and charge pharmacist did not notice the error during the checking process.

There were a number of opportunities for the pharmacist to realise the error, including evidence that indicated the woman was probably breastfeeding; however, he failed to do so.

After taking the incorrect medication, the woman was taken to the emergency department at the local hospital, and admitted. She remained in hospital overnight, and was discharged the following day.

The pharmacy had appropriate standard operating procedures in place and was not vicariously liable for the pharmacist's breach. It was held that the error was the responsibility of the charge pharmacist, who unreservedly apologised to the woman. However, this does not excuse the fact that he was not alert to the error during the dispensing process, missing several significant opportunities to have noted it. He also failed to comply fully with reporting procedures. By failing to provide pharmacy services with reasonable care and skill, and in compliance with professional standards, the pharmacist breached Rights 4(1) and 4(2). He was referred to the Director of Proceedings, who issued proceedings before the Health Practitioners Disciplinary Tribunal. A charge of professional misconduct was upheld and the pharmacist was fined $5,000 and ordered to pay costs of $5,000. The Tribunal also recommended that the Pharmacy Council undertake a competency review of the pharmacist.

Link to Health Practitioners Disciplinary Tribunal decision:

http://www.hpdt.org.nz/Default.aspx?tabid=172