In a report released today, deputy health and disability commissioner Rose Wall found the pharmacist had breached the Code of Health and Disability Services Consumers’ Rights for failing to check the correct medication was dispensed to a consumer.
In April 2021 Alexandra woman Mikayla Wilson picked up what she thought was a routine prescription for acne from Lake Dunstan Pharmacy in Cromwell. The pharmacy has since sold.
The mistake was discovered three weeks later when she returned with the original medication package and the last remaining pills for a script repeat.
The pharmacist who dispensed the original medication told Miss Wilson the prescription box had the correct information on it, but the contents did not match.
They apologised and told her not to worry as there were no issues with it, Miss Wilson said.
She was given the correct medication and told to continue taking it from that point.
It was not until nearly three months later during an unrelated doctor’s visit where Miss Wilson learned the doctor had not been told of the mix-up.
Inquiries by her doctor revealed it was not acne medication, but acitretin, a psoriasis drug not meant for women of child-bearing age due to the complications it could pose.
The deputy commissioner was critical the pharmacist did not provide Miss Wilson with a clear explanation about the adverse side effects of taking the incorrect medication after the dispensing error was discovered.
‘‘In my view, a reasonable pharmacist should conduct a thorough and comprehensive review about an incorrectly dispensed medication and inform the affected patient immediately about potential adverse side effects,’’ Ms Wall said.
‘‘It is clear that at the time of discovering her error, the pharmacist checked for information about the dispensed medication, but did not appreciate that there were serious side effects.
"Accordingly, I am critical that the consumer did not receive a clear explanation about the adverse side effects of the medication she had taken.’’
The pharmacist accepted full responsibility for her error, telling the commission she had processed the correct medication, isotretinoin, through her computer software correctly, but she had ‘‘inadvertently dispensed acitretin 10mg in error’’ and did not identify the error in her final check.
The pharmacist stated the isotretinoin may have been stored in the wrong place at the time, and potentially had been moved by another staff member in error.
The pharmacy stored its medications alphabetically so the two drugs should have not been stored together; however, she and another pharmacist recalled seeing the isotretinoin in the wrong location next to the acitretin.
She also explained the dispensary was busy at the time the error occurred, with increased interruptions and only two rostered staff members working at any one time.
Ms Wall recommended the pharmacist formally apologise to Miss Wilson and report back on the learnings she had taken from the incident.
The pharmacy’s dispensing and checking standard operating procedures also came under fire for not highlighting look-alike medications on the dispensary shelves, and for not having a step-by-step process for dispensing and checking in accordance with the Pharmacy Council’s standards.
It was recommended the pharmacy undertake an audit of its existing standard operating procedures.
