Page Section: Centre Content Column
Risperidone dispensed instead of prednisolone (06HDC01037)
Download Risperidone dispensed instead of prednisolone (06HDC01037) (PDF 131Kb)
(06HDC01037, 24 August 2006)
Pharmacy ~ Pharmacy technician ~ Dispensing error ~ Right
4(1)
A family complained about a dispensing error whereby risperidone
(an anti-psychotic drug) was dispensed rather than prednisolone
cough syrup. The medicine was given to a child, just under three
years old at the time, by her mother, and the child quickly
deteriorated, resulting in an emergency admission to a public
hospital. She recovered rapidly and was discharged a couple of days
later with no lasting effects.
The dispensing error was made by a pharmacy technician, and the
error was not picked up as, contrary to the standard operating
procedure, the technician used all of, and discarded, the bottle
used first (the incorrect risperidone) and topped up to the full
amount with a small amount of the correct prednisolone. When the
pharmacist checked the dispensed drug, all she considered was the
prednisolone bottle, and was unaware that another bottle had been
used. Therefore she had no chance to correct the technician's
error.
It was held that in dispensing risperidone instead of the
prescribed prednisolone, disposing of the empty bottle of
risperidone, and placing Dermol cream meant for another patient in
the bag containing the prescription, the pharmacy technician failed
to provide the child with services of an appropriate standard, and
breached Right 4(1). The matter was referred to the Director of
Proceedings.
It was also held that the standard operating procedure in place
at the time (which stated that all the bottles used to dispense a
medication should be retained to check) was adequate. Consequently,
the pharmacy did not breach the Code.
The Director of Proceedings decided to issue proceedings before
the Human Rights Review Tribunal. On 19 December 2007 the Tribunal
made a declaration by consent that the pharmacy technician had
breached Rights 4(1) and 4(2).
Link to Human Rights Review Tribunal
decision:
http://www.nzlii.org/nz/cases/NZHRRT/2007/25.html