Pharmacist ~ Dispensing error ~
Dosage ~ Checking ~ Standard operating procedures ~ Systems review
~ Professional standards ~ Right 4(2)
An ophthalmologist prescribed a 42-year-old woman a short-term
course of prednisone to prevent the development of cystoid macular
oedema (inflammation of the retina).
He prescribed 30mg of prednisone to be taken on a daily basis
for the first two weeks, followed by a reduced dosage of 20mg daily
for the next two weeks. Prednisone comes in 1mg, 5mg and 20mg
doses. Although the correct number of tablets was dispensed, the
pharmacist mistakenly selected the 20mg tablets instead of the 5mg
The woman suffered severe side effects from ingesting four times
the intended dose. As the ophthalmologist had warned the woman that
there might be side effects, at first she did not give too much
thought to them. After five days, however, she contacted the
ophthalmologist as she thought the reactions were more severe than
had been indicated.
The ophthalmologist was surprised that the woman's reactions
were so adverse to what was a relatively low dosage. However, over
the next few months the dosage was altered to take into account the
woman's apparent sensitivity. A further script was filled for 1mg
prednisone. The woman alternated her dose, but what was meant to be
alternations between 5mg and 4mg was in fact between 20mg and 4mg.
Erratic reactions to the medication continued.
The dispensing error was discovered only when the woman compared
her medication to the prednisone prescribed to her mother.
The pharmacy had stored both the 5mg and the 20mg tablets on a
cabinet shelf in white containers that were essentially the same
except for a purple band and an orange band, respectively. Although
the different dosages come in different colours, this distinction
is not obvious when the tablets are put into brown-tinted glass
As a result of the error, the pharmacist introduced an
additional checking measure. He now leaves the container from which
a prescription is dispensed on the counter until the prescription
is collected, rather than return it to the shelf upon filling the
script. The container is then checked against the script.
It was held that although the pharmacist had documented standard
operating procedures that had been recently audited, his practice
did not meet professional standards, as evidenced by his failure to
pick up his error with checking procedures. This amounted to a
breach of Right 4(2).