Page Section: Centre Content Column
Fluoxetine dispensed instead of prescribed Tramadol (15HDC01810)
Download Fluoxetine dispensed instead of prescribed Tramadol (15HDC01810) (PDF 73Kb)
Pharmacist ~ Pharmacy ~ Dispensing error ~ Checking ~
Professional standards ~ Right 4(2)
A 32-year-old woman was prescribed 30 "TRAMADOL 50mg tabs" for
pain relief following a wisdom tooth extraction. Her mother
presented the prescription to a pharmacy for dispensing.
The pharmacist interpreted the prescription as being for
Arrow-Tramadol 50mg capsules, but mistakenly selected from the
shelf 30 fluoxetine 20mg capsules, rather than 30 tramadol 50mg
capsules. The fluoxetine capsules were repackaged out of the
manufacturer's packaging into a plain white packet, which was then
labelled as containing tramadol capsules. The pharmacist became
distracted while labelling the packet and so did not check the
contents, as done usually and as is required by the pharmacy's
Standard Operating Procedures (SOPs).
The dispensing was checked by a second pharmacist, who did not
identify the dispensing error. The pharmacy told HDC that the
second pharmacist's normal practice was to open packets to make
sure the correct medicine and strength had been selected, as is
required by the pharmacy's SOPs. However, the second pharmacist
advised that, on this occasion, the packet may have been opened,
but, because the strips of capsules were the same size as that of
tramadol capsules, the medication may not have been removed from
the packet for a more thorough check.
The dispensing error was discovered by the woman's mother a week
later. The woman took up to 20 fluoxetine capsules over the space
of one week, and took six capsules (totalling 120mg) on at least
one day during this time.
It was held that the first pharmacist failed to ensure that the
correct medication was dispensed, in accordance with the
professional standards set by the Pharmacy Council of New Zealand
and with the pharmacy's SOPs. The pharmacist therefore failed to
provide the woman with services in accordance with professional and
other relevant standards, in breach of Right 4(2).
The second pharmacist failed to check the dispensed medication
adequately, in accordance with the professional standards set by
the Pharmacy Council of New Zealand and with the pharmacy's SOPs.
The pharmacist therefore failed to provide the woman with services
in accordance with professional and other relevant standards, in
breach of Right 4(2).
The dispensing error was the pharmacists' alone. The pharmacy
had appropriate SOPs in place, as well as a sufficient number of
trained staff working at the time. The pharmacy did not breach the
Code, and was not vicariously liable for the pharmacists' breach of
It was recommended that the pharmacy randomly audit its staff
compliance with SOPs (for dispensing and checking medications) over
a one-month period and report back to HDC. Both pharmacists had
already apologised to the woman.