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Prescription and dispensing of incorrect dose of medication to child (15HDC01542)
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15HDC01542, 16 December
Paediatric registrar ~ Pharmacist
~ District health board ~ Pharmacy ~ Prescribing error ~ Dispensing
error ~ SOPs ~ Rights 4(1), 4(2)
A young girl, aged two years and 11 months, experienced painful
and difficult urination following bladder surgery. She was reviewed
by a paediatric registrar at a public hospital. After discussion
with a senior colleague, the paediatric registrar prescribed
medication for her including oxybutynin, which is primarily
indicated for the management of urinary urgency and
The paediatric registrar chose an appropriate dose of 2mg
oxybutynin, but instead of writing "oxybutynin 2mg" three times
daily for ten days on the prescription form, wrote "oxybutynin
20mg", three times daily for ten days, which was a ten times higher
The girl's father took the prescription forms to the pharmacy
for the medications to be dispensed. The receiving pharmacist
noticed that the oxybutynin dose seemed high but did not question
it at the time. The prescription forms are not initialled to show
who completed the dispensing. The medications were placed in a bag,
and the bag was placed in the delivery basket at the pharmacy. A
second pharmacist delivered the medication to the girl's mother.
The second pharmacist said that she omitted to discuss the
medication with the mother, but discussed a separate health
The mother gave the girl the prescribed dose of oxybutynin after
she had ongoing pain with passing urine. The girl experienced side
effects and was taken to the hospital's Emergency Department, where
she was monitored and discharged later that day.
It was the paediatric registrar's responsibility to ensure that
she prescribed a clinically appropriate dose of oxybutynin. By
failing to do so, she did not provide services with reasonable care
and skill, and breached Right 4(1). It was considered that if
electronic prescribing had been available when the medication was
prescribed, it could have minimised the risk of this error
The first pharmacist failed to take steps to contact the
prescriber when she noticed that the oxybutynin dose seemed high.
She also did not sign on the date stamp to indicate that she had
dispensed and/or checked the prescriptions in accordance with the
pharmacy's Dispensing Prescriptions Standard Operating Procedure
(SOP). It was held that the pharmacist did not provide services in
accordance with professional standards, and breached Right
It was found that the second pharmacist did not check the
prescriptions, calculations and labels, did not ensure that the
Dispensing Prescriptions SOP was followed, and missed an
opportunity to check the appropriateness of the prescription at the
time of delivery of the medications to the girl's mother. It was
held that, in all the circumstances, the second pharmacist did not
provide services with reasonable care and skill, and breached Right
Non-compliance with the Dispensing Prescriptions SOP played a
part in the girl receiving an inappropriate dose of oxybutynin.
Accordingly, it was held that the pharmacy did not provide services
with reasonable care and skill and breached Right 4(1).
The Commissioner recommended that the paediatric registrar, the
two pharmacists and the pharmacy each provide a written apology to
the girl's parents.
The Commissioner recommended that the DHB introduce systems to
allow a specific space for the recording of a child's weight on
prescriptions; give feedback to HDC on the implementation of its
new electronic prescribing system, and use this case as an
anonymised case study for education for paediatric medical
The Commissioner recommended that the pharmacy undertake two
audits of compliance with its Dispensing Prescription SOP, and use
this case as an anonymised case study for education for future
employees of the pharmacy.
The Commissioner recommended that the Pharmacy Council of New
Zealand consider whether a review of the first pharmacist's
competence is warranted.
The Commissioner recommended that the Ministry of Health
actively continue to support the rollout of electronic prescribing
across New Zealand's DHBs in both inpatient and outpatient
settings, and work with the sector to progress an integrated
approach to medicines management.