A baby stopped breathing after an overdose when a pharmacist trainee put the wrong dosage on a medicine label. (File image) Photo:
A pharmacist breached a health code of conduct by dispensing the wrong dose of medication to a four-week-old baby, who was later admitted to hospital.
A report by Deputy Health and Disability Commissioner Dr Vanessa Cardwell found the pharmacist failed to provide services of an appropriate standard.
The report said in 2023, the baby was prescribed the oral steroid drug Redipred by her GP to treat croup symptoms.
The medication dispensed by the pharmacy was incorrectly labelled to give a 4.5ml dose, which was five times the prescribed dose of 4.5mg.
The report said after the baby received close to the full dose as written on the medication, she stopped breathing. She was given CPR by her mother and then admitted to hospital for treatment and monitoring.
The medication label had been typed by a trainee pharmacy technician and then checked by an experienced pharmacist who was a locum at the pharmacy, Cardwell said.
"In addition to not properly checking the dispensed medication against the prescription, or not identifying the error on the prescription dosage, the pharmacist also failed to provide advice to the mother on how to administer the medication," she said.
"These failings meant the pharmacist did not adhere to the professional standards set by the Pharmacy Council of New Zealand or the pharmacy's own SOP, and accordingly breached the Code, which gives consumers the right to appropriate standards."
Cardwell said this would have been an "extremely traumatic and distressing experience for the baby's parents, and the mother had commented that she had still be unable to process what had happened".
The report stated the pharmacist said the trainee pharmacy technician who was processing the baby's prescription misread the unit when entering the information into the dispensary software.
The pharmacist accepted it was her responsibility to check the units as the checking pharmacist, and did not apportion blame to the dispensary software or the pharmacy technician, the report said.
Caldwell said the report highlighted the importance of pharmacists undertaking adequate checks, following process and guidelines on the dispensing of medication, and of managing dispensing errors and complaints.
It also highlighted the importance of pharmacies providing adequate training to staff to ensure that processes were followed, she said.
Cardwell acknowledged changes had been made by the pharmacist and the pharmacy since the event.
Cardwell's recommendations included that the pharmacist provide a formal written apology to the baby's parents, and complete training on handling paediatric prescriptions.
She recommended the pharmacy undertake a random audit of the overall processing, dispensing, and checking of medication of 50 prescriptions over a one-month period to assess compliance with the
processing, dispensing, clinical appropriateness, and checking of prescriptions.
The report said the pharmacist had been referred to the Pharmacy Council.