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Medication dispensing error (13HDC01618)
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(13HDC01618, 13 January
Pharmacist ~ Dispensing error ~ Medication selection ~ IVF
treatment ~ Incident management ~ Right 4(2)
A woman who was undergoing a frozen embryo transfer as part of
her in vitro fertilisation (IVF) treatment was prescribed
"Oestradiol Valerate" as part of her treatment. The prescription
was faxed to the pharmacy and the woman went to the pharmacy to
pick it up.
The pharmacist who processed the prescription entered the first
four letters of the medication - "oest" - into the pharmacy
computer software in order to generate the label. The medication
that came up on the screen was oestriol (brand name Ovestin), which
the pharmacist selected. The oestriol was then packaged and
dispensed to the woman. The woman took the oestriol in accordance
with the prescription instructions.
A few weeks later, on day 14 of the woman's menstrual cycle, she
started spotting. The woman went to see her doctor and at that time
the woman questioned the medication she had been taking and it was
discovered that she had been dispensed an incorrect form of
oestrogen (oestriol rather than the correct oestradiol valerate).
As a result of taking the wrong medication, the woman's embryo
transfer cycle had to be abandoned.
The woman later returned to the pharmacy to take back the
oestriol and pick up the oestradiol valerate. At that time, the
woman spoke to another pharmacist. The woman recalls the pharmacist
said that she was sorry for the error, and that it was a computer
It was held that by failing to check the medication he was
dispensing against the original prescription, the pharmacist failed
to provide the woman with services in accordance with professional
standards. Accordingly, the pharmacist breached Right 4(2).
It was accepted that the standard operating procedures (SOPs)
for dispensing medications in place at the pharmacy at the time of
this incident were appropriate, and that the pharmacist was aware
of the dispensing requirements. Furthermore, there is no evidence
that the pharmacy was particularly busy at the time of the
incident. It was concluded that the pharmacy was not responsible
for the pharmacist's breach of the Code.
Adverse comment was made about the pharmacy's incident
management in this case.