The Health & Disability Commissioner has found a pharmacist in breach of the Code of Patients’ Rights after he prescribed a different patient’s medication to the wrong patient.

The patient had attended the pharmacy and when she thought her name was called went into the consulting room with the pharmacist.  Unfortunately the pharmacist had actually called another patient with a similar sounding name.  The pharmacist says that he repeated the correct patient’s name to the person in the consulting room and she did not say that was not her.  The patient claims that the pharmacist did not repeat the name and she had no idea that she was the wrong patient. 

The pharmacist then proceeded to dispense the medication and gave it to the patient to take, which she did.

It was only upon leaving the consulting room that another staff member informed the pharmacist that he had given the medication to the wrong patient.  The pharmacist then spoke to the patient about the incident.  By a stroke of good luck the medication given to the patient for the other patient was actually the same medication that the patient was supposed to have received, but just an incorrect dose.  Luckily the dose was less than what she should have received so she was then able to receive the correct top up dose.

The Health & Disability Commissioner considered that the pharmacist had breached the code because he had not carried out enough checks in the consulting room to make sure he had the right patient.  It was only extreme good fortune that the patient received the same medication as the patient who had been called.  The pharmacist was to apologise and to undertake refresher training on the correct dispensing of medication with checking of patient details.

Alan Knowsley
Medical Lawyer