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Double error dispensing insulin (14HDC00551)
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(14HDC00551, 19 June
Pharmacy ~ Pharmacist ~ Diabetes medication ~ Dispensing
error ~ Incident reporting ~ Rights 4(1), 4(2)
A woman visited a pharmacy on two occasions to have a
prescription filled for her son who is diabetic. On both occasions,
the woman was given the wrong insulin - Humulin NPH (a
medium-acting insulin) instead of Humulin 30/70 (a mixture of
short- and medium-acting insulin).
On the first occasion, the first pharmacist selected, labelled
and checked the medication dispensed for the son. Because of the
difference in packaging, the woman realised that there was an error
and, within three days, she contacted the pharmacy to tell it about
the error. The correct medication was then delivered to the
On the second occasion, which was two months after the first
occasion, the second pharmacist checked the medication dispensed
for the son, but it was not clear who completed the other steps of
the dispensing process on that occasion.
Twelve weeks after the first incident, an incident reporting
form for the first incident was completed by the first pharmacist.
Approximately a week later, an incident reporting form was
completed for the second incident by the charge pharmacist, after
receipt of the complaint to HDC.
It was held that by failing to select the correct medication and
then check the medication being dispensed to the woman on the first
occasion, the first pharmacist failed to provide services in
accordance with professional standards and, as such, breached Right
By failing to appropriately check the medication being dispensed
on the second occasion, the second pharmacist failed to provide
services in accordance with professional standards and, as such,
breached Right 4(2).
Adverse comment was made about the first and second pharmacists'
failures to promptly fill in incident reporting forms in relation
to the incidents.
Overall, the pharmacy did not have appropriate processes in
place to support safe dispensing practices, thereby breaching Right