The Health and Disability Commissioner has recommended that a Pharmacist apologise, and a Health Board apologise and perform an audit, after a child was given the incorrect medicine.

A pharmacy received an order for the child’s medicine from his doctor. Despite being standard practice for two pharmacy staff to check that prescriptions are correct, only one pharmacist prepared and checked the child’s medicine.

The Pharmacist accidentally prepared a different medicine with a similar name and the error was not detected. The child took the medicine for several weeks before being admitted to hospital.

When the child was admitted, the hospital noted that the prescribed medicine was not common and did not have any immediately available. Instead, the family was asked to provide the child’s medicine from home.

Despite nurses being responsible for checking the medicine every time it was given to the child, the prescription error was not detected on four occasions.

On the fifth occasion that the child was to be given medicine by a nurse, the error was detected and brought to the attention of hospital staff and the pharmacy responsible.

The Commissioner held that the Pharmacist breached the child’s right to have services provided that comply with legal, professional, ethical, and other relevant standards, and that the Health Board breached his right to have services provided with reasonable care and skill.

The Commissioner recommended that the Pharmacist and Health Board provide an apology to the child’s family, and that the Health Board perform an audit to ensure staff are complying with the relevant policy about patients using their own medications.

It is important that all healthcare practitioners take particular care to ensure that patients are prescribed and given the correct medicines. Mistakes where incorrect medicines are provided may result in negative health outcomes for patients, and potentially serious disciplinary consequences for the practitioners responsible.

If there are concerns about the services that have been provided to you by a healthcare practitioner, it is wise to speak with a professional experienced in the area.

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Christian Merten
Rainey Collins Lawyers
Wellington, New Zealand


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