Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the dispensing error was a ‘significant incident’ because of the apparent harm caused. Photo / James Gilberd Photography.
The woman told the Health & Disability Commissioner that the antidepressant, sertraline, taken in conjunction with other prescribed medication she took for anxiety, caused “serotonin syndrome”, described as a toxic state caused mainly by excess serotonin in the central nervous system.
She fainted and had other symptoms, including nausea, diarrhoea, uncontrollable sweating, a racing heart, hypertension, and hypotension.
She sought help at a hospital after-hours clinic and required “multiple” GP visits afterwards.
The woman then notified the pharmacy of the dispensing error once she became aware of it, Deputy Health & Disability Commissioner Dr Vanessa Caldwell said in a decision released today.
Caldwell found the dispensing error was a “significant incident” because of the apparent harm caused.
Similar brand names led to error
The pharmacy stated that the error was the result of confusion caused by similarities between the brand name of the prescribed medication and the medication dispensed in error.
It has since revised its standard operating procedure for dispensing to emphasise that medications should be processed under their generic names, not brand names.
Caldwell found the pharmacist who checked the prescription in breach of a section of the health consumer’s code, and was critical of the technician who prepared it.
The pharmacy told the HDC that in June 2024, its dispensing software had identified that the woman was due for her repeat prescriptions.
After it was processed, it was dispensed by a pharmacy technician who selected the medications, applied computer-generated labels, and placed the medications in a basket for checking by a pharmacist.
The medication was then checked, bagged up and placed on a shelf for collection.
Caldwell said, based on evidence from the pharmacy, it appeared the technician misread the label and selected sertraline 50mg instead of cyproterone 50mg.
She said the error was not picked up by the pharmacist when he did a final check, likely for the same reason.
Caldwell said she notified the pharmacist of the pending HDC investigation last February, and a month later, he accepted that his conduct was in breach of the code.
He and the pharmacy had since apologised to the woman, placed additional warning signs on the medicine shelf next to the two medications in question, and further staff training on standard operating procedures and the dispensing process had been completed.
Caldwell said the HDC’s office had said in a similar case that it was a “fundamental patient safety and quality assurance step in the dispensing process” to adequately check the medication being dispensed against the prescription.
This involved checking that the correct medicine, dose, form, strength, and quantity were being dispensed, and checking for any interactions.
Caldwell said a check of therapeutic appropriateness, or that it was the correct medication for the indication, would have identified the error, the same as checking whether the medication would interact negatively with the woman’s other prescribed medication.
Responsibility lay with pharmacist
She said while the onus was on the technician to dispense the medication correctly, the ultimate responsibility for the final check lay with the pharmacist.
She said that by not carrying out the final check adequately, he failed to adhere to industry standards and the pharmacy’s own operating procedures.
Among a list of recommendations, including that the technician also apologise to the woman, Caldwell advised the pharmacy do a random audit of medication for 20 prescriptions, to assess staff compliance with the dispensing and checking procedures.
The pharmacy then had to report the outcome to the HDC and any action plan to address the findings.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.