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Decision 98HDC15457
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Complaint
The complainant complained to the
Commissioner about services provided to her late father, the
consumer, by the pharmacy.
The consumer was prescribed
"0.0625 mg Digoxin tablets - take 2 tablets daily." In
mid-April 1998 the pharmacy dispensed 0.25mg digoxin tablets. The
label on the bottle of tablets stated "Digoxin 0.0625
mg".
Investigation
The complaint was received by the
Commissioner on 22 June 1998 and an investigation was undertaken.
Information was obtained from:
The Complainant
The Manager of the Pharmacy
The bottle of digoxin
tablets was acquired and a copy of the prescription obtained from
Health Benefits Limited.
Information Gathered During Investigation
The consumer was prescribed
"[d]igoxin 0.0625 mg - take two tablets daily". In
mid-April 1998 the pharmacy dispensed digoxin tablets, the label
stated that digoxin 0.0625mg had been dispensed.
Six days after the prescription was
dispensed the consumer stayed with his daughter, the complainant.
The complainant, a nurse, observed that the digoxin
tablets her father had been dispensed were white. From her nursing
experience, the complainant thought that digoxin 0.0625mg
tablets were blue tablets not white.
Four days after her father had come
to stay with her the complainant contacted the pharmacy to check
the colour of digoxin 0.0625mg tablets. The manager
confirmed to her that digoxin 0.0625mg tablets are blue.
The complainant then queried why her father's tablets were white in
appearance. The manager was unable to provide an explanation but
suggested that the medication had been incorrectly dispensed.
The manager was also unable to
advise the complainant who the dispensing pharmacist was. The
original prescription was obtained from Health Benefits Ltd. The
form was not signed by the dispensing pharmacist. The manager has
accepted responsibility for the matter.
The Code of Health and Disability Services Consumers'
Rights
RIGHT 4
Right to Services of an Appropriate Standard
...
2) Every consumer has the right to have services provided that
comply with legal, professional, ethical and other relevant
standards.
...
Pharmaceutical Society of New Zealand Code of
Ethics
Rule 2.12 states
"A pharmacist must dispense the specific medicine prescribed
?
Rule 2.13 states
"The pharmacist responsible for a dispensed product must always
be readily identifiable ?each prescription must be annotated with
the initials of the person dispensing the prescription and the
initials of the pharmacist responsible for the dispensed
product."
Opinion: Breach
In my opinion the manager breached
Right 4(2) of the Code of Health and Disability Services Consumers'
Rights.
I was unable to identify the
individual pharmacist who dispensed the consumer's digoxin
as the prescription form was not signed. The manager advised the
Commissioner that there were no written protocols or procedures for
dispensing at the pharmacy. As manager of the pharmacy the manager
must therefore take responsibility for the actions of the
dispensing pharmacist.
Digoxin 0.25mg was
dispensed in error and no record kept of who dispensed the tablets.
By doing this the manager failed to comply with relevant
professional standards as contained in the Pharmaceutical Code of
Ethics and therefore breach of Right 4(2) of the Code.
Actions
I recommend that the manager:
- provide a written apology for the breach of the Code of Rights
to the consumer's family;
- establish procedures and policies to ensure dispensing is
checked independently where possible, and prescription forms are
signed for by the dispensing pharmacist;
- confirm to the Commissioner that these procedures and policies
on dispensing and checking of medication are in place.
A copy of this opinion will be
forwarded to the Pharmaceutical Society of New Zealand.
For further information, contact:
HDC Communications Section (09) 373 1060 or by email: your.rights@xtra.co.nz