Health Practitioners Disciplinary Tribunal, 877/Phar16/366D,(10 February 2017)
The Director of Proceedings filed a charge against registered pharmacist, Mr Zelcer, in the Health Practitioners Disciplinary Tribunal (“the Tribunal”) concerning his management of a dispensing error affecting his patient, Mr R (“the consumer”).
On 15 October 2013 Mr R was dispensed cyclophosphamide 50mg tablets in error instead of his prescribed cyclosporine 50mg capsules. Mr R is a kidney transplant recipient and takes cyclosporine 50mg capsules as part of his immunosuppressant therapy to prevent organ rejection. Cyclophosphamide 50mg, the medication he was dispensed in error, is a cytotoxic agent predominantly used in combination chemotherapy regimes. It can also be used as an immunosuppressant when in the opinion of the physician the benefits to the patient outweigh the risk of treatment with that agent. Sometime in November 2013 Mr R began taking the cyclophosphamide 50mg tablets and it is estimated he consumed 35 tablets over a 2.5 week period and was therefore not taking his prescribed cyclosporine 50mg for that period of time.
On 4 December 2013 Mr Zelcer discovered the dispensing error when Mr R returned to the pharmacy for an unrelated medical test and asked Mr Zelcer about the difference in appearance between the cyclosporine 50mg he had been dispensed on 15 October 2013 and subsequent cyclosporine 50mg medication he had been dispensed (cyclophosphamide at the time came as pink tablets whereas cyclosporine came as white capsules). Mr Zelcer immediately realized that a dispensing error had occurred and that Mr R had been dispensed cyclophosphamide 50mg tablets instead of his prescribed 50mg cyclosporine capsules. Mr Zelcer misled Mr R by not telling him he had been dispensed cyclophosphamide 50mg and instead telling him he had been dispensed a “discontinued product” and by extension not telling Mr R that the medication he had been dispensed and had been taking was not his prescribed cyclosporine 50mg.
Mr Zelcer advised Mr R to stop taking the tablets dispensed on 15 October 2013 and to immediately start taking the cyclosporine 50mg capsules he had been dispensed on a later occasion by the pharmacy. Mr Zelcer did not ascertain how many tablets of cyclophosphamide 50mg Mr R had taken nor did he contact Mr R’s GP to tell him about the dispensing error and importantly that Mr R had not been taking his prescribed immunosuppressant medication. Mr Zelcer did not complete an incident report and did not tell the pharmacy manager about the dispensing error.
The error was discovered by the pharmacy manager on 6 December 2013 when Mr R returned to the pharmacy and asked to speak to the manager in private and then showed the manager some of the remaining cyclophosphamide 50mg tablets he had in his possession. Mr R asked what they were. The manager subsequently spoke to Mr Zelcer who admitted the details of the dispensing error. The pharmacy manager immediately ascertained how many cyclophosphamide 50mg tablets Mr R had taken in error and then phoned Mr R’s GP and explained what had occurred. Mr R’s GP took advice from the Nephrology Department at Canterbury DHB and an urgent blood count and kidney function test were arranged. The pharmacy manager then phoned Mr R and explained what had occurred, apologizing for the error and the way it was handled.
The matter proceeded by way of an agreed summary of facts whereby Mr Zelcer accepted that he had acted in a way which amounted to professional misconduct as per s 100(1)(a) or (b) of the Health Practitioner’s Competence Assurance Act 2004 (“the Act”). The Tribunal agreed that Mr Zelcer’s behaviour constituted malpractice or negligence and was conduct that has brought or was likely to bring discredit the profession and concluded the allegation of professional misconduct had been made out.
In considering penalty the Tribunal accepted the submission made on behalf of Mr Zelcer that he always intended to report the matter and address it appropriately but that he made an error of judgment in not concluding there was immediate urgency about this. In reaching this conclusion the Tribunal placed emphasis on Mr Zelcer’s experience and some 30 years of unblemished practise.
The Tribunal’s formal orders included censure of Mr Zelcer, a $5,000 fine and two conditions on his practise, that for 12 months he practise under the mentorship of a Council approved Senior Pharmacist and that he attend a course approved by the Pharmacy Council which relates to dealing with stressful and difficult situations. Mr Zelcer was also ordered to pay 30% of the costs associated with the proceedings.
Mr Zelcer was declined an order for permanent name suppression with the Tribunal noting there had not been enough information placed before it to enable the Tribunal to depart from the “default position of publication”. An order for permanent name suppression was made for Mr R and his family as well as the name of the pharmacy manager and the pharmacy where the events occurred and the pharmacies (and owners thereof) where Mr Zelcer currently works.
The Tribunal’s decision (and an addendum) can be found at:
Last reviewed February 2019