‘Burn-out’ led to dispensing errors


A pharmacist was censured and fined over $5,500 after he dispensed methadone without a valid script and allowed take-home doses when in-person dosing was required

Stuff reports that an Auckland pharmacist made numerous mistakes when dispensing methadone, and faced the Health Practitioners Disciplinary Tribunal as a result.

It was alleged that the pharmacist, identified only as Mr A due to an interim name suppression, had been dispensing methadone to several patients in concerning ways between 2013 and 2017.

This included allegedly dispensing methadone to patients who did not have a valid or current script.

In one case, a patient was given a double dose of their methadone, and in two others, the patients were given a higher dose than had been prescribed for them.

It was also alleged that the pharmacist had dispensed the opioid replacement therapy to a patient as four take-home doses – but this patient was restricted to in-store dosing only.

Another patient was allegedly given a split dose which had not been prescribed.

The Professional Conduct Committee argued that the pharmacist’s behaviour had constituted “serious lapses in professional practice”.

There had been significant potential for harm, with the Auckland Opioid Treatment Service reporting “near misses,” said the Committee’s lawyer.

Mr A’s counsel told the Tribunal that some of the 12 particulars pertinent to the allegations, when taken on their own, did not require a sanction.

In one case, for example, she told the Tribunal that the patient had a script for 25 doses of methadone – and while these were entered, the end date was incorrect.

When the pharmacist dispensed three additional doses as a result, this was inadvertent, she said.

While this was potentially negligent and he should have read the script correctly, such a mistake did not warrant a sanction, she argued, telling the Tribunal that most of the behaviour constituted such “careless” single-incident mistakes.

A “sudden and dramatic increase” in these mistakes took place in 2017, Stuff reports, and the pharmacist became very stressed.

He was suffering “burn-out” but did not realise the impact it was having on the way he practised pharmacy, his lawyer said – or that the errors had been so numerous.

He admitted the charge cumulatively, and agreed that when taken as a whole, the errors constituted professional misconduct.

He also said he was “extremely grateful” that nobody had been seriously harmed.

The pharmacist was censured and fined NZ$6,000 (AUD$5,598).

Conditions were placed on his registration – though he is not currently practising – including that he must complete further training on methadone before he is able to dispense it again.

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