Dispensing errors do not meet professional standards of care

Assistant Health and Disability Commissioner Deborah James today released a report finding a pharmacist and pharmacy in violation of the Health and Disability Consumer Rights Code (Code) for failing to provide services in accordance with professional standards.

On two occasions, the pharmacist mistakenly dispensed Ropin 1 mg instead of Rolin 1 mg to a woman in her 90s. Ropin is used to treat Parkinson’s disease and restless legs syndrome, while Rolin is used to treat advanced breast cancer in postmenopausal women.

Pharmacists should carry out comprehensive checks on medicines before they are dispensed.

However, in this case, the pharmacist did not check the woman’s medication history and did not identify the error when he compared the label to the prescription.

The error was pointed out by the woman’s mother who noticed that her tablets were different from normal. Once the pharmacy became aware of the error, they did not take appropriate action to prevent the error from recurring.

A second dispensing error involving the same drugs occurred several months later.

On this occasion, the pharmacist undertakes each step of the dispensing and control process herself instead of having her work checked by another pharmacist or taking a break between the dispensing and the final check, which was the standard of care. expected.

The pharmacist again failed to adequately review the woman’s medication history, which means that the previous error was not identified, and an indicator requiring discussion with the woman and her mother before submissions. medication was also missed.

The Deputy Commissioner found that the pharmacist had failed to provide services in accordance with relevant professional standards as set out by the Pharmacy Council of New Zealand and the pharmacy’s Standard Operating Procedure (SOP).

Deborah James also criticized the pharmacist’s handling of incidents as a result of errors.

“A pharmacy is responsible for ensuring the provision of safe and appropriate services, which includes putting in place adequate policies and guidelines. She is also responsible for ensuring that staff adhere to these policies and guidelines, ”said Deborah James.

“While there is individual responsibility for errors, I am concerned that the staff have not complied with the SOPs in several respects, which I see as evidence of a failure of the pharmacy to help its staff in such a way. adequate to sensitize them to the requirements of the SOPs. and actively encourage and support staff to follow them, ”she said.

Deborah James recommended that the pharmacy perform a staff compliance check with the updated dispensing process SOPs, and provide details of the actions that have been taken to resolve the issues identified.

She also recommended the pharmacy:

-Initiate an audit of staff compliance with updated SOPs on delivery errors.

-Use an anonymized version of the report to inform their staff;

-Provide HDC with a log of “near misses” and details of actions taken to resolve identified issues;

-Provide evidence of staff training logs, demonstrating training in the Pharmacy SOP;

-Modify relevant policies to include retention of written records of staff meetings / discussions and actions required as a result of distribution errors.

The full report for case 20HDC00036 is available on the HDC website.

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