Page Section: Left Content Column
Page Section: Centre Content Column
Error in packaging and delivery of medication (04HDC15595)
Download Error in packaging and delivery of medication (04HDC15595) (PDF 138Kb)
(04HDC15595, 19 August 2005)
Pharmacist ~ Pharmacy ~ Blister pack medication ~ Retirement
village ~ Packaging error ~ Standard operating procedures ~ Right
A woman complained about the services provided by a pharmacy to
her elderly, visually impaired mother. The elderly woman rang the
pharmacy and requested a repeat of her monthly blister pack
medication. Medication is put into blister packs as an explicit
safety precaution to ensure that patients take their correct
medications in the correct doses, and the woman had her medication
dispensed in blister packs because she was partially sighted and
was required to take a number of medications.
The prescription was delivered to the main desk at the woman's
retirement complex, and the following day she started taking the
new blister pack medication. A day later it was discovered that she
had been taking another patient's morning blister pack.
The pharmacist explained that this was an inadvertent error
which, he believed, had occurred when the correctly dispensed
blister packs for the woman and the second patient became mixed up
at the time they were put into a bag for delivery to the woman.
It was held that, by failing to comply with legal and
professional standards, the pharmacist breached Right 4(2). It is
critical that pharmacy staff exercise caution and ensure that
prescriptions are properly separated throughout the entire
dispensing process. It was also held that the error was not due to
any inadequacy of the pharmacy's repeat dispensing practices or
other systems errors. Accordingly, no issue of vicarious liability
arose in relation to the pharmacy.
Page Section: Right Content Column
Top of Page