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Medication dispensing error (14HDC01530)
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Pharmacist ~ Pharmacy ~ Medication dispensing ~ Medication
selection ~ Right 4(2)
An eight-year-old child was prescribed 60 x 840mg sodium
bicarbonate capsules for the treatment of Fanconi's syndrome, a
disorder of the kidney tubules whereby the body is unable to absorb
certain substances normally.
The child's mother took the prescription to a pharmacy. A
trainee technician processed the prescription and generated a label
that stated: "sodium bicarbonate CA 840mg". However, the person who
then dispensed the medication dispensed 60 zinc capsules (50mg) in
error. The zinc capsules were in their original bottle. The staff
member attached the label that stated sodium bicarbonate to the
bottle of zinc capsules. The original label for zinc capsules was
still visible. The staff member failed to initial the child's
prescription, so the pharmacy was unable to confirm the identity of
the staff member.
A second pharmacist checked the dispensing. As part of her
checking process, the second pharmacist opened the medication
bottle to check inside. Zinc and sodium bicarbonate capsules are
similar in appearance, and the pharmacist did not recognise the
error. In addition, she did not notice the words "Zincaps", "zinc
supplement" or "50mg" on the outside of the bottle.
The child started taking the zinc capsules dispensed by the
pharmacy about four months later. The child later suffered
epileptic seizures, unrelated to having taken zinc capsules, and
was admitted to hospital. The child's mother took the child's
medications with him to the hospital, in case he needed them while
he was there.
The hospital pharmacist undertook a medications reconciliation
(comparing his physical medication with the medication he had been
prescribed). The pharmacist noticed that zinc capsules had been
dispensed rather than sodium bicarbonate and notified the child's
mother, the ward doctor, and the pharmacy of the error.
It was held that the pharmacist who checked the dispensing
failed to adequately check the dispensing and as a result failed to
identify the error. Accordingly, the pharmacist failed to provide
services in accordance with professional standards and breached
Criticism was made of the pharmacy's failure to ensure that all
staff complied with its dispensing SOP and that these errors led to
an unsatisfactory service being provided by its staff members.