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Dispensing error: tenoxicam instead of tamoxifen (13HDC01235)
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Pharmacy ~ Pharmacist ~ Dispensing medication ~ Selection
error ~ Insufficient measures ~ Standard operating procedures ~
Inadequate care ~ Right 4(1)
In 2012 a woman underwent a bilateral mastectomy and
chemotherapy due to breast cancer. Consequently, she was prescribed
a five-year course of tamoxifen, a drug for the treatment of breast
cancer. She started the course in mid-2012.
In 2013, she presented a repeat prescription at the pharmacy for
a further three-month supply of tamoxifen. She noticed that the
tablets she was dispensed were different from previous ones.
However, she attributed the difference in appearance to funding
changes and took the tablets for three months.
Five months later, the woman returned to the pharmacy to collect
a further supply of tamoxifen tablets. Upon collecting the
tamoxifen tablets, she noticed a return to the round white pills
she was used to.
The woman queried with staff at the pharmacy about the changes
in the medication. It was then established that she had been
dispensed tenoxicam instead of tamoxifen five months earlier.
Tenoxicam is described as an antirheumatic, anti-inflammatory and
The pharmacy undertook an investigation to determine how the
error occurred. It was noted that the woman's prescription was
correctly entered into the computer, as a label for 20mg tamoxifen
was generated. However, tenoxicam 20mg was incorrectly selected
from the shelf and dispensed to the woman.
At the time of the error, the pharmacy's standard operating
procedures (SOPs)required that the dispenser and checker must be
able to be identified at all times. However, the pharmacy was
unable to identify the pharmacist responsible for the dispensing
error, as the woman's prescription was not initialled by the
It was held that the pharmacy's failure to have sufficient
measures in place within the pharmacy environment to ensure
knowledge of, and compliance with, its SOPs played a significant
part in the woman receiving the incorrect medication. In
particular, the pharmacy failed to place an alert or precaution
notice near the tamoxifen and tenoxicam, did not regularly review
and update its SOPs, was unable to demonstrate that staff read the
SOPs and, despite being aware of ongoing non-compliance with the
dispensing SOP, failed to enforce compliance. Accordingly, the
pharmacy did not provide services to the woman with reasonable care
and skill and breached Right 4(1).