A supervising pharmacist who did not realise a man had accidentally been given someone else’s Parkinson’s medication prescription three times failed to “provide services of an appropriate standard”, the Health and Disability Commissioner says.
The incidents began in December 2021, when a man went to pick up a prescription faxed by his GP to his pharmacist which was printed on four double-sided pages.
The final page contained a prescription for a Parkinson’s Disease medication called Sinemet, which was intended for another patient at the same practice.
A Health and Disability Commission report released today said the prescription was processed by an “experienced” intern pharmacist, who noted that the medication was new for the man but did not identify that it was not prescribed for him. The supervising pharmacist checked the prescription and also did not identify that the medication was prescribed for another patient.
In her report, Deputy Health and Disability Commissioner Deborah James noted the man had “difficulty communicating in English, as this was not his first language”, and he had a high level of trust in health professionals, including his doctor and community pharmacy.
The man took the Sinemet medication and returned for two further repeats over a period of three months, before complaining to his GP of dizziness and imbalance in March 2022.
The GP then contacted the pharmacy and an internal investigation confirmed the error.
The man told HDC he had experienced “ongoing issues with his health” since he was dispensed Sinemet including a dry mouth, dry nose and eyes, for which he now required ointments.
“His sleep and physical activity have also been affected, and he suffers from dizziness and numbness in his hands and feet,” the report said.
James found the supervising pharmacist to have breached the Code of Health and Disability Services Consumers’ Rights for failing to provide services of an appropriate standard across several areas.
“By failing to verify patient details on each of the pages of the prescription during the checking process, [the pharmacist] did not follow the pharmacy’s Dispensing and Processing a Prescription SOP or the PCNZ Competence Standards (2015) correctly,” she said.
She also said “opportunities were missed to identify the dispensing error and prevent a further two repeat prescriptions being issued” in the days following dispensing of the original prescription.
Since these events, James acknowledged the pharmacy had made several changes to improve systems and prevent future errors.
These included retraining staff, updating SOPs, and switching to either emailed prescriptions or the New Zealand ePrescription Service.
Pharmacists were also reminded to slow down and ensure that their full attention was given to each task, especially when dispensing was busy.
In addition to these changes, James recommended records of completion of dispensing staff training be provided to HDC and auditing of last 15 prescriptions where a new medication has been dispensed.
