My experience with an AHPRA notification

A few weeks ago, I received an email which made me think my life would change forever…

The email was a notification from AHPRA informing me that a complaint had been made against me for a dispensing error I had made several weeks before.

The email included a complaint from the affected consumer and it informed me I had to provide a written response with a deadline of two weeks from receipt of the email.

Here’s what happened:

A script was presented for 2 packs of Serepax. I supplied 2 bottles of the generic brand Alepam not realising one of the bottles was not Alepam but was instead a bottle of Kinson. The patient had been taking Kinson for two-and-a-half weeks (before realising the error). During that time she had reported to, “Feeling generally unwell and lethargic and with legs like lead.”

The patient unfortunately did not contact me when she discovered the error but instead reported it directly to AHPRA.

My first reaction was panic and I feared my pharmacy registration would be cancelled. How would I then pay my bills, let alone face my family and friends? I was unsure what to do next and fell into a state of depression.

The following day at my workplace, I informed my pharmacy manager, who restored a glimmer of hope within me. He reminded me that PDL could provide assistance to pharmacists in this situation and he encouraged me to call the incident support service immediately, which I did.

I was put through immediately to a Professional Officer who put my mind at ease, confirming that as a member, I was entitled to advice and support and he explained the process to me. It was a great relief to speak to a pharmacist who understood what I was going through. I was given some practical advice on what my response to AHPRA should entail from a pharmacist’s perspective.

It was explained to me that with legal input, my response would focus on acknowledging my dispensing and labelling error, detailing ways that could prevent the error occurring again. A lawyer assigned to me helped me draft a response.

I described how I would be more diligent in scanning whenever possible in the future. Furthermore, I was instructed to check my scanning history at the end of each day so that my scanning percentage was approaching 100% of items that could be scanned.

This improved scanning practice was referenced as part of my response to the AHPRA enquiry.

The lawyer assisting me explained that AHPRA has a duty of care to protect the public from medical misadventure, so any improvement on my behalf would be viewed favourably. With professional help through PDL, I was able to submit my response to AHPRA before the required deadline.

Now it is just a matter of waiting for a decision from AHPRA, which I am told can take upwards of sixty days. In the meantime, I feel reassured that I can call PDL’s Professional Officer at any time with questions or concerns that may arise, or if I generally need peer support.

Yesterday, I was contacted by a pharmacist friend who had been through a similar AHPRA experience to mine. In her opinion, she said that it is highly unlikely that AHPRA would take punitive steps against me for a first time dispensing error.

My friend was issued with a caution from AHPRA which I found to be a fair result, the message from AHPRA was conveyed that she needs to lift her standard of practice in the future. She explained that a caution does not show on the AHPRA register of pharmacists, but it could be taken into account if further complaints were made against her. This news came as a great relief.

My overall experience in having an AHPRA notification made against me has been one of great stress and uncertainty. However, with the expert advice and support of PDL Professional Officers and the legal team, I have not felt alone or overwhelmed by my situation.

I feel that I have learned from this experience and I will endeavour to be a better pharmacist through improved processes and practice.

PDL has lobbied manufacturers of some Look Alike Sound Alike (LASA) products to differentiate the packaging.

Product changes to date have occurred with Alphapharm, Sandoz and Mundipharma. Reports to PDL highlight that LASA comprise a significant amount of dispensing errors in the pharmacy profession.

Call 1300 854 838 if this topic raises any concerns for you. PDL membership includes 24/7 access to speak with a Professional Officer for immediate advice and incident support, Australia wide.

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  1. Gavin Mingay

    Why are people still not scanning every box?? It takes half a second and ensures you get it right…

  2. Jeff Lerner

    You wrote:
    ” … my response would focus on acknowledging my dispensing and labelling error, detailing ways that could prevent the error occurring again. A lawyer assigned to me helped me draft a response.”

    My first thought when reading your account was:

    Were you given any evidence by AHPRA of your ALLEGED dispensing error – e.g. photograph/s clearly showing your pharmacy labels?

    If not, then I certainly hope that your insurer and/or your assigned lawyer would have requested this before allowing you to accept responsibility for an ALLEGED incident.

    Years ago I received a phone call from a very irate customer claiming that I’d given him the wrong tablets. He said he was too busy to return to the pharmacy and demanded that I immediately despatch by taxi (at my expense) the correct item. I declined to do this, and asked him to return with the ‘wrong’ item.

    What he brought back was a container supplied about a year previously by a different pharmacy.
    I don’t think there was any deliberate attempt at deceit. It appeared that he was a hoarder and was simply confused about his stash of drugs.

  3. William

    My comments will only be about avoiding such errors in the future, not the legal issues or customer handling.
    There is no substitute to reading each label and checking it against the source document, in this case the original prescription. That is the basic thing to do; relying on scanning or other means are a help but should be subservient to a professional process.
    The other issue to address would be the storage of the products: how did such dissimilar products get to be stored so close to each other or be on the dispensing bench near each other?
    What type of checking is done in this pharmacy before giving to the patient?
    There are a lot of comments about us being a profession so let’s start to act in a professional manner.

    • Shahriar Kashani-Malaki

      Agreed. AHPRA’s regulation is a large part of what makes us a profession.

      Levodopa/Carbidopa may be stored next to Oxazepam in some dispensaries

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