HDC Case: Pharmacist Dispensing Error and Dishonest Conduct 25 May 2020

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a pharmacist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for a dispensing error, and dishonest conduct following the error.

Source: Health and Disability Commissioner

19HDC00989

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a pharmacist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for a dispensing error, and dishonest conduct following the error.

A woman requested a repeat prescription of rifaximin, an antibiotic. A pharmacy technician incorrectly selected rivaroxaban, a medication used to treat blood clots, and the pharmacist failed to detect the error when he checked and dispensed the medication. The woman took the incorrect medication for eight days, then was admitted to hospital with internal bleeding and acute kidney injury resulting from the incorrect medication.

When the pharmacist, who was the managing director of the pharmacy, found out about the dispensing error, he claimed another pharmacist had dispensed the medication. He altered the pharmacy’s records to show it was the other pharmacist’s error, then disseminated that information to staff and the Pharmacy Defence Association. He later admitted that the error was his.

Kevin Allan was critical that the pharmacist failed to follow the pharmacy’s standard operating procedure and complete the necessary checks to avoid dispensing incorrect medication. "As a result of [the pharmacist’s] omission, [the woman] consumed incorrectly dispensed rivaroxaban and suffered significant adverse health complications that required admission to hospital," Mr Allan said.

Mr Allan was particularly concerned about the pharmacist’s dishonest and unprofessional conduct on discovering the error.

"[The pharmacist] abused his position as a senior pharmacist and manager to manipulate the adverse event investigation," Mr Allan said. "[His actions] were dishonest, unacceptable, and a clear breach of ethical and professional obligations."

The pharmacist has since sold his interest in the pharmacy and stopped practising. Kevin Allan recommended that the pharmacist apologise to the woman, and that the Pharmacy Council consider whether to review his competence if he returned to practise. Mr Allan referred the pharmacist to the Director of Proceedings for the purpose of deciding whether any proceedings should be taken.

Mr Allan also recommended that the pharmacy arrange refresher training for its staff, and audit staff compliance with standard operating procedures and any errors and near misses in relation to the dispensing of medicines.

The full report for case 19HDC00989 is available on the HDC website.

https://www.hdc.org.nz/decisions/search-decisions/2020/19hdc00989/