Bellamere Duncan’s parents were allegedly given an adult dosage of phosphate by a pharmacy in Manawatū.
The revelations prompted the Ministry of Health and Health NZ to “urgently” undertake a joint review into the incident. The Pharmacy Council was also investigating.
Health NZ said in a statement today that it had completed a serious adverse event review after Bellamere’s death.
MidCentral chief medical officer Dr Claire Hardie said that, while Bellamere’s death remained before the Coroner, she died after an unintentional overdose of oral phosphate.
“The purpose of the Serious Adverse Event Review was to identify opportunities for learning and improvement so we can reduce the chances of such a tragedy happening again.
“The review process has included whānau, clinicians, Medsafe and representation for the community pharmacy provider which dispensed the prescription for oral phosphate.”
Hardie said the review highlighted there were “multiple factors” at play.
“Those factors included discharge planning, communication with the family and community pharmacy process.”
The review identified “recommended actions for improvement”, such as updated guidance for managing Metabolic Bone Disease in premature infants at MidCentral, and strengthening clinical documentation.
It also recommended training on safe prescribing and administration of paediatric medications, review of discharge procedures within the Palmerston North Hospital neonatal unit, and developing a process for changes to any discharge plan to be clearly documented.
It also supported the introduction of electronic prescribing for outpatients nationally.
“We are committed to implementing the recommendations from the review which fall within our responsibilities and have an action plan and monitoring programme in place to support this work.
“We would like to extend our condolences to the whānau for their loss and thank them for sharing their experience as part of the review process. The learnings from this review are helping us to put processes and improvements in place that should prevent such a tragedy from happening again.”
Three staff involved in error
The owner of the Manawatū pharmacy earlier emailed Bellamere’s parents with a summary of what happened.
The owner said the pharmacy’s standard dispensing process involved intern pharmacists entering each prescription into the dispensary computer. The pharmacy used a dispensing system called Toniq.
A technician would then use the information in Toniq and the prescription to identify the medication and put the correct amounts in containers. The labels were printed out and placed in a basket with the original prescription and the medication. A registered pharmacist would then check the prescription, the labels and the medication itself before it was given to the patient.
The owner said the pharmacy received the prescription by email on July 1 from Palmerston North Hospital.
The prescription was entered into Toniq by an intern pharmacist.
“This person unfortunately misread the prescribed dosage and entered the prescription dose as ‘1 tablet twice daily’ rather than ‘1.2 mmol twice daily’,” the owner said.
The Toniq system then generated an original label for the prescription.
“This includes a warning label with the patient’s age, if they are under 18 years old, and if the patient has not been prescribed the medication before.
“The second warning prompts the checking pharmacist to counsel (speak with) the patient or their caregiver about how to take the medication.”
The product was supplied in tubes of 20 tablets. The trainee technician printed out three further labels. They were to be placed on the three tubes that were being dispensed.
“This was the trainee technician’s first time handling a phosphate product. She was also unfamiliar with the mmol dosage. She did not notice the dosage error as a result. She put the original prescription, labels and the medication in a basket on the dispensing bench for the registered pharmacist to check.
“Unfortunately, the original label and the warning label were not kept with other items.”
The registered pharmacist who carried out the final check did not pick up that the medication was for an infant, the owner said.
“In addition, it was not identified that this was a new medication. The fact that the warning label was not retained contributed to this error.”
– RNZ