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Risperidone dispensed instead of prednisolone (06HDC01037)

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(06HDC01037, 24 August 2006)

Pharmacy ~ Pharmacy technician ~ Dispensing error ~ Right 4(1)

A family complained about a dispensing error whereby risperidone (an anti-psychotic drug) was dispensed rather than prednisolone cough syrup. The medicine was given to a child, just under three years old at the time, by her mother, and the child quickly deteriorated, resulting in an emergency admission to a public hospital. She recovered rapidly and was discharged a couple of days later with no lasting effects.

The dispensing error was made by a pharmacy technician, and the error was not picked up as, contrary to the standard operating procedure, the technician used all of, and discarded, the bottle used first (the incorrect risperidone) and topped up to the full amount with a small amount of the correct prednisolone. When the pharmacist checked the dispensed drug, all she considered was the prednisolone bottle, and was unaware that another bottle had been used. Therefore she had no chance to correct the technician's error.

It was held that in dispensing risperidone instead of the prescribed prednisolone, disposing of the empty bottle of risperidone, and placing Dermol cream meant for another patient in the bag containing the prescription, the pharmacy technician failed to provide the child with services of an appropriate standard, and breached Right 4(1). The matter was referred to the Director of Proceedings.

It was also held that the standard operating procedure in place at the time (which stated that all the bottles used to dispense a medication should be retained to check) was adequate. Consequently, the pharmacy did not breach the Code.

The Director of Proceedings decided to issue proceedings before the Human Rights Review Tribunal. On 19 December 2007 the Tribunal made a declaration by consent that the pharmacy technician had breached Rights 4(1) and 4(2).

Link to Human Rights Review Tribunal decision:


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