Pharmacy ~ Pharmacist ~ Prescribed
medicine ~ Labelling error ~ Standard operating procedures ~ Right
A woman complained about the services provided by a pharmacy,
when she received incorrectly labelled medications.
The woman was prescribed liquid suspensions of paracetamol and
erythromycin by her general practitioner for severe tonsillitis.
The liquid suspensions were correctly prepared by the pharmacy
technician. However, the pharmacist transposed the labels for
paracetamol and erythromycin, and as a result the medications were
There was nothing distinctive about the medication bottles to
alert the woman to the error. Accordingly, she took the medication
as directed and took more erythromycin than she intended (the
precise quantity cannot be ascertained) and less paracetamol (a
total of 60ml) over the following two-day period. Two days later
the GP further advised the woman to increase her liquid paracetamol
intake and to cross over to an oral form as soon as she could
swallow. As a result, she unintentionally further increased her
erythromycin dosage and inadvertently continued with 30ml per day
of paracetamol. When she began taking oral paracetamol, her
antibiotic regime was interrupted, as she had inadvertently ceased
taking erythromycin, and she took additional paracetamol from the
bottle labelled "erythromycin". When she obtained a repeat
erythromycin prescription from another pharmacy she realised the
error that had occurred.
It was held that, in failing to comply with legal and
professional standards, the pharmacist breached Right 4(2).