Dispensing error on pharmacist’s first day

A pharmacist accidentally dispensed sertraline instead of sumatriptan to a teenager… a mistake discovered over six months later

A New Zealand pharmacist failed to adhere to professional standards by mistakenly dispensing sertraline to a teenager who had been prescribed sumatriptan for migraines, the country’s health commissioner has found.

The teenager’s mother presented with a script for sumatriptan 50mg tablets at what was the busiest time of day at the pharmacy.

A dispensary technician was present in the pharmacy at the time and dispensed the medication. The two medications, sertraline and sumatriptan, were reportedly next to each other on the shelf.

Meanwhile the pharmacist at the centre of disciplinary proceedings was on duty. It was her first day working at the pharmacy, where she had taken on the role of manager.

Prior to starting this job, she had worked in hospital pharmacies as a clinical pharmacist, and in other pharmacies as a pharmacist manager.

The pharmacist undertook the final check of the prescription and medication, but she did not notice that sertraline 50mg tablets had been dispensed instead of sumatriptan 50mg tablets.

The error was discovered over six months later by the teenager’s school nurse.

In subsequent disciplinary proceedings, the pharmacist told the Health and Disability Commissioner that her checking process failed her when checking the prescription for the patient.

She explained that a possible factor that caused the error was that it was her first day at the pharmacy and it was a new environment.

The pharmacy said while the pharmacist had met with staff to become familiar with the dispensary layout, she’d had no formal handover from the previous pharmacist manager because this person had already left the pharmacy before she started.

However the pharmacist accepted that the wrong medicine was dispensed owing to human error.

“While it was [the pharmacist’s] first day at the pharmacy, she was a pharmacist with more than 20 years’ experience and was appointed as the manager. I acknowledge that the names of the two medications are similar, but [she] had a professional responsibility to take appropriate steps to ensure the provision of safe and accurate services,” found Deputy Health and Disability Commissioner Kevin Allan.

By allowing an incorrect medicine to be dispensed, the pharmacist breached the health code by failing to adhere to the professional standards set by the Pharmacy Council of New Zealand, Mr Allan found.

However he noted she had taken reasonable steps to manage the incident appropriately once she was made aware of the error.

After the dispensing error was discovered, the pharmacist immediately informed the patient’s GP, provided a verbal apology to the patient’s mother, and notified her indemnity insurer.

She also immediately separated the two medications, sertraline and sumatriptan, on the pharmacy shelf far from each other with a red sticker underneath saying to be aware of name similarity.

A few days after the error was discovered, the pharmacist sustained an injury while on leave, causing her to be off work for four months.

Mr Allan found the pharmacy itself breached the health code by consequently failing to attempt to retrieve the incorrectly dispensed medication, contact the patient’s mother or undertake an investigation during this time.

The pharmacy told the Commissioner that the delay in investigation was caused by the pharmacist’s accident, and the time it took to respond was affected by increased workload over the COVID-19 period, in conjunction with the pharmacist requiring a long period off as a result of her injury.

However Mr Allan said: “The failure to undertake an adequate review … represented a missed opportunity to identify how the error occurred, and to identify actions to minimise such errors in the future.”

The teenager’s mother told the Commissioner that the issue has caused her daughter to struggle to take medications. She also commented that, at the time, “all she wanted was an apology and empathy and felt she received neither”.

Mr Allan recommended that the pharmacy provide a written formal apology to the patient’s mother for breaching the code.

He also recommended that the pharmacy arrange refresher training for its staff and undertake an audit of dispensing and checking processes to assess compliance.

The pharmacy said that it would consider employing an extra pharmacist when a new pharmacy manager is starting, if the pharmacy manager has not been able to become familiar with the team and layout prior to commencing employment.

Meanwhile the pharmacist escaped disciplinary measures. She informed the Commissioner that she is making changes to her practice, including reviewing her checking procedure and analysing near miss logs.

She is also completing a workbook on improving accuracy and self-checking, and provided a written apology to the patient’s mother.

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  1. JimT

    I remember my 1st day being registered (over 40 years ago) and started working as the sole pharmacist in the pharmacy due to owner taking urgent leave. On the way home that day I literally had to stop driving and just chill out on the way home. There was 1 item I still remember caused me grief. It was a promethazine 25mg tablet script. I was torn between Phenergan or Avomine – both promethazine compounds of same strength. I contacted Doctor at the 1st opportunity the next day and he was very blasé over this, but it kept me up all night. Not an error per say but shows how the first day can be ever so stressful….

  2. Anne Todd

    Interesting no discussion of a bar-code scan check in any of this dispensing process? is that not the norm in NZ as well as Australia.

  3. Peter Allen

    How it happened: having worked in hospitals prior, where drugs are stored under their GENERIC names, the S-drughs same strength presumably ‘generic equivalents.’ in her subconscious

    An explanation,,, No excuse however.

    Plus not following it up– is SO much worse!

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