Error death exposed ‘critical failure in pharmacy practice’

pharmacist in dispensary

PDL has highlighted the importance of taking patient concerns and questions seriously, after a dispensing error contributed to a patient’s death

In a recent coronial inquest, it was found that the pharmacist’s error was a contributing factor in the death of an elderly customer from rhabdomyolysis.

The patient, who had multiple health issues, was prescribed Simvastatin 40mg – but at the pharmacy, she was given Rosuvastatin 40mg tablets instead.

The patient’s husband queried the medication, pointing out that the dispensed item appeared to be different to the usually supplied product.

“When asking about the discrepancy, an unidentified staff member said words to the effect of, ‘It’s alright. Maybe it’s a different box’,” observes PDL.

“It may be this person was a pharmacy assistant. Thus, an opportunity to carefully investigate the error was missed.”

The patient was admitted to hospital, where the error was discovered and rhabdomyolysis was identified.

The cause of death was determined to be rhabdomyolysis.

“In recommendations from the inquest, the Coroner directed that the ‘Pharmacy Guild of Australia review the circumstances of the consumer’s death for the purpose of education, awareness and the creation of robust dispensing policies and guidelines”.

PDL notes that all Australian pharmacists would be aware of the many published dispensing guidelines available, including PDL’s Guide to Good Dispensing, the Pharmacy Board’s Guidelines for dispensing, PSA’s Professional Practice Standards and dispensing protocols formulated by various pharmacy banner groups.

It says that the “critical failure in pharmacy practice” exposed by this patient’s death underlines the fact that consumer concerns and queries should always be taken seriously.

“PDL are aware of similar situations where consumer questions have been handled by unqualified staff, instead of being referred to the pharmacist,” it says.

“A typical answer by unqualified staff is, ‘It may be just a generic version’.

“To prevent such errors occurring, pharmacy managers are advised to instruct their staff to refer all questions around medication to the pharmacist on duty.

“Such referrals should be carefully investigated by that pharmacist because, as this case demonstrates, the consumer’s concerns may be justified.”

PDL encourages its members to make use of its Guide to Good Dispensing, available from its website here.

PDL members with concerns or questions about this or other topics can contact PDL on 1300 854 838, for 24/7 advice and incident support from a Professional Officer.

Readers who are distressed can contact the Pharmacists’ Support Service on 1300 244 910 or at

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  1. Jarrod McMaugh

    This highlights not only the importance of accuracy and taking responsibility for errors, but also that rhabdomyolysis as a side effect of statin therapy is not a “theoretical” issue. These medications are not innocuous, and side effects from them can and do happen.

    • Amandarose

      It’s also interesting that rosuvastatin 40 is supposed to only be initiated by specialists but the number of people started on it by a GP sometimes as a first drug is astounding.

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