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Reporting of dispensing error (14HDC00439)
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(14HDC00439, 24 June
Pharmacist ~ Pharmacy technician ~ Pharmacy ~ Dispensing
error ~ Incident report ~ Open disclosure ~ Information ~ Rights
4(2), 4(4), 6(1)
A man presented at a pharmacy to have a new prescription filled
and to pick up a repeat of his regular medication. One of the
medications for repeat was cyclosporine 50mg. Cyclosporine is an
immunosuppressant used to prevent rejection following transplants.
The man had previously had a kidney transplant. Cyclosporine
capsules are white, sealed with foil, and dispensed in a cardboard
The prescriptions were processed by the pharmacy technician.
Cyclophosphamide 50mg tablets were selected from the shelf instead
of cyclosporine 50mg capsules. Cyclophosphamide is a chemotherapy
drug used to treat certain types of cancer, and is dispensed as
small pink tablets in a bottle. The pharmacist checked the
medications and initialled the dispensing record for each repeat
Approximately seven weeks later, the man presented at the
pharmacy for a regular test. After the test, the man showed the
cyclophosphamide tablets to the pharmacist, and enquired as to why
the tablets were different from his regular cyclosporine capsules.
The pharmacist told him that the tablets were a "discontinued
product", and that he should stop taking them. The man left the
cyclophosphamide tablets with the pharmacist.
Following the consultation, the pharmacist immediately looked up
who had dispensed the cyclophosphamide tablets and noted that the
prescription had been processed by the pharmacy technician and the
dispensing record signed off by himself. The pharmacist then
changed the stock levels on the pharmacy's computer system. The
pharmacist did not complete an incident form or notify the pharmacy
owner of the error. The pharmacy owner was away from the pharmacy
at the time the pharmacist became aware of the error, but returned
approximately 20 minutes later.
Later that same day, the pharmacy owner processed an order for
medications, and noted that there was no remaining stock of
cyclophosphamide tablets. The pharmacy owner questioned his staff
about this, but the pharmacist did not disclose the error.
Two days later, the man returned to the pharmacy and asked to
speak to the pharmacy owner in private. The man showed the pharmacy
owner the remaining cyclophosphamide tablets in his possession, and
outlined the pharmacist's explanation for the tablets. The pharmacy
owner told the man that he would look into the matter further.
Following the pharmacy owner's conversation with the man, the
dispensing error was discovered, and the pharmacy contacted the man
and his GP to alert them to the incident. The pharmacy also
undertook an internal investigation.
By making a serious dispensing error, the pharmacist did not
comply with professional standards and was in breach of Right 4(2).
The pharmacist also breached Right 6(1) by failing to disclose the
dispensing error to the man as soon as he became aware of it. The
pharmacist's failure to report the error was in breach of the
pharmacy's policy, and professional standards, and a breach of
Right 4(2). For failing to take appropriate actions to mitigate the
risk of serious harm to the man, the pharmacist breached Right
Adverse comment is made about the pharmacy technician's error in
selecting cyclophosphamide 50mg tablets instead of cyclosporine