Photo: 123RF
A supervising pharmacist breached a man's rights by giving him medication for Parkinson's disease that was not prescribed to him, the deputy Health and Disability Commissioner has found.
The man's prescription was faxed by his GP to his pharmacist and was printed by the pharmacy as four double-sided pages. The final page contained a prescription for Sinemet, a medication for Parkinson's disease, which was intended for another patient at the same practice.
The intern pharmacist who processed the prescription noted that Sinemet 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 the medication was prescribed for another patient.
The man returned two more repeat prescriptions and the error was discovered when he complained of dizziness and imbalance. The GP contacted the pharmacy and an internal investigation confirmed the error.
This happened in 2021-2022.
Deputy Health and Disability Commissioner Deborah James found the supervising pharmacist did not follow the standard operating procedures (SOPs) for processing, dispensing and checking prescriptions, which have been designed to prevent such errors from happening.
There was also no documentation of the required counselling conversation with the man about the new medication.
The pharmacy has made several changes since the event to prevent future errors, including retraining staff, updating SOPs, and switching to ePrescriptions.
Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.