A pharmacist has been censured for giving a customer nearly seven times their usual dose of methadone and failing to follow professional guidelines.
A customer consumed another patient's methadone dose - almost seven times their usual dose. File image Photo: RNZ /Dom Thomas
Health and Disability Commissioner Morag McDowell released a report finding the pharmacist to be in breach of their professional duties.
The customer, who was in his 60s at the time, had been prescribed a daily dose of methadone to treat previous intravenous drug use and lung disease.
He arrived at the pharmacy and lined up for his daily 11mg dose of methadone.
The pharmacist prepared a 75mg dose for a patient ahead of the man, and turned away for a moment to fill up the cup.
"While the pharmacist had turned away to measure the correct dose for that client into a cup, the client left the room, and the man - who had been standing behind the intended client but was unseen due to his size - stepped forward and was waiting when the pharmacist returned to the counter with the dose he had just measured," the Commissioner said.
The man was inadvertently given and consumed the other patient's methadone dose of 75mg - almost seven times his usual dose, and potentially life-threatening.
The pharmacist informed the man of the error as soon as he realised what had happened, but he let the man drive home without advising him of the risks.
McDowell has asked the pharmacist to apologise to the man's family, and undergo a professional assessment through the Pharmaceutical Society of New Zealand.
She also recommended the pharmacy review and update its operating procedures and arrange refresher training for its staff.