‘Reckless’ prescribing errors caught by vigilant pharmacists

Pharmacists detected a litany of dangerous prescribing errors by a struggling doctor who has now been suspended

A NSW doctor has admitted he was operating “out of his depth” when engaged in solo practice from 2016 to 2018, during which time he made several prescribing errors related to 11 patients.

At the time, the GP was living 700km away from family to practise in a regional town of NSW, where he juggled a heavy workload of approximately 50 patients per day plus attending to other patients in aged care facilities.

Methotrexate mistakes

In November 2017 the practitioner prescribed 10mg methotrexate with the direction “10mg twice daily for 1 week and wean to 10mg daily for 1 month” for Patient D, a 16 year old complaining of back pain, in circumstances where the dose was excessive and posed a risk of side effects.

The GP admitted this was “my mistake” and that prescribing methotrexate daily rather than weekly is dangerous and could cause “pancytopenia and the risk of septic shock”.

He gave evidence that he was well aware at the time that methorexate was a weekly and not a daily dose and that the mistake was an oversight due to being too busy, experiencing frequent interruptions and being very stressed.

The GP had reportedly received a previous warning in the form of a phone call from the local pharmacist about the same mistake in relation to this patient a few years prior, which was evidenced by a Clinical Intervention report.

In a decision handed down last month, the NSW Civil and Administrative Tribunal considered that the repeated identical errors constituted professional misconduct.

Furthermore, in 2016, the practitioner prescribed 10mg methotrexate with the direction “20mg daily m.d.u” and 5mg folic acid (folate) with the direction “5 b.d.m.d.u” to a different patient (Patient E) in circumstances where the dose of methotrexate and folic acid was excessive and posed risks of side effects including liver/renal failure, immunosuppression and infections.

Again the doctor admitted to the conduct but stated that he meant to direct the medication to be taken weekly.

‘Reckless’ prescribing

Patient G, aged 73 years, attended in August 2016 for “erection issues, pain, insomnia”. They had been prescribed Viagra 18 months earlier.

The GP said the patient was not happy with Viagra and decided to change the patient’s medication to Cialis.

He admitted he made an error and prescribed Ciazil (citalopram), an antidepressant, instead of Cialis. The respondent admitted he did not read the prescription on the computer screen before printing it, did not read the prescription hardcopy when he signed it, and did not read it before handing it to the patient.

“Were it not for the clinical intervention of the pharmacist on 27 August 2016, the patient would have commenced on an antidepressant medicine that can have an adverse effect on electrical conduction in the heart, among other adverse effects; and that would worsen his erection difficulties,” said the Tribunal.

After the respondent was contacted by the pharmacist, he wrote a prescription for Cialis, without dosing instructions. The prescribing error was not recorded.

The drug prescribed in error (Ciazil) was not cancelled/ceased in the medical records. Thus, on 23 August 2016, the patient was prescribed Ciazil, Cialis (no dosing instruction) as well as Viagra (no dosing instruction).

The Tribunal found the respondent was “reckless” in his prescribing and found professional misconduct proven in this instance.

Patient H, aged 13 years, attended for travel advice in April 2016, accompanied by his father.

The respondent said he considered Malarone as an anti-malarial, but when he phoned the pharmacist, there was no supply available. The doctor then decided to prescribe doxycycline. He admitted he made a mistake and prescribed Doxepin at 50mg daily instead.

“Were it not for the clinical intervention from the pharmacist, the child would have commenced on a medicine for major depression that is not recommended in Australia for use in children because it raises the risk of suicidal thoughts or actions in children and young adults,” stated the Tribunal.

Following a phone call from the pharmacist, the GP said he wrote a prescription for doxycycline, the correct medicine. However the prescribing error was not recorded, nor was Doxepin cancelled/ceased in the medical records.

On this complaint, the Tribunal again found the doctor’s prescribing to be “reckless” and constituted professional misconduct.

Patient I, a 16 year old complaining of acne, consulted the practitioner in July 2016. The doctor prescribed 50mg Doxepin with the direction”1 bd m.d.u” and a local application, Epiduo Gel.

The respondent again admitted he mistakenly prescribed Doxepin instead of doxycycline. The Tribunal noted this error occurred barely three months after the pharmacist had phoned the respondent to point out an identical error with Patient H.

“The pharmacist recorded in the clinical intervention that the doctor was ‘advised to check his prescriptions carefully as this is dangerous’,” it said.

The GP did not record the prescribing error although, this time, he did record ceasing Doxepin.

A further case involved Patient J, for whom the practitioner prescribed Q fever injection 25mcg/0.5mL ignorant of the necessity to check the patient for prior immunity or allergy.

The pharmacist phoned the practitioner to check if the necessary tests had been completed. “Were it not for the clinical intervention from the pharmacist, Patient J would have been at considerable risk of vaccine reaction that can be potentially disastrous,” said the Tribunal.

Patient K consulted the practitioner on 11 July 2017. She was a 69-year-old new patient who sought repeat prescriptions for Tertroxin that she has been taking for hypotension.

The GP decided to prescribe levothyroxine 75 mcg as he considered this the nearest equivalent to Tertroxin. However, he prescribed baclofen (Lioresal) instead. The medical records showed that both levothyroxine and Lioresal were prescribed at that visit.

He did not know how he made that mistake, saying he was unfamiliar with the name baclofen. However this unfamiliarity did not cause him to read the medicines information on baclofen.

The dispensing pharmacist noticed the error and phoned the doctor to advise on what he should have prescribed. The prescribing error was not recorded, nor was the error drug ceased/cancelled in the records.

“But for the clinical intervention of the pharmacist, Patient K would have been on a medicine that has a not insignificant range of adverse effects,” said the Tribunal.

“The majority of such errors in prescribing were detected by the pharmacists who were issuing the medications. Such pharmacists invariably contacted the practitioner to advise him of apparent errors in prescribing. In some cases the dosage was incorrect; in others the wrong drug had been prescribed by the respondent,” the Tribunal found.

Tribunal findings handed down

The HCCC alleged the doctor was guilty of professional misconduct, which he did not admit.

However he acknowledged that he was “totally out of my depth whilst working as a sole practitioner”. He has now ceased working as a sole practitioner.

He added: “I appreciate that the allegations raised in relation to the nominated patients reflect a serious deficiency in my clinical knowledge and the delivery of proper medical service at the time.

“I am extremely grateful that no adverse outcomes occurred and in this regard, I am extremely grateful for the competency of the pharmacist in detecting the errors.”

The Tribunal found the conduct constituted professional misconduct, ordering a reprimand and a four-month suspension, reduced from six months as two months of suspension were already served.

Practice conditions apply for a minimum of two years following suspension, including group practice, working under supervision and limits on numbers of patients.

The GP will be subject to audits, with particular attention to prescribing.

He was ordered to pay costs to the HCCC.

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  1. Debbie Rigby

    Example of Swiss Cheese model of medicine safety, highlights critical role of a pharmacist dispensing in identifying medication errors and ensuring patient safety. Also highlights the need for separation of prescribing and dispensing. Needs greater acknowledgment by medical organizations

  2. Jarrod McMaugh

    Noting that this doctor was experiencing significant stress over the period of time that he was operating on his own, I wonder if the medical board has referred him to supportive services to assist with this?

    I’m sure his stress levels have not improved after being reprimanded in this manner

  3. Michael Ortiz

    This case is particularly interesting. Not because of the mistakes made by the GP, rather it is what the pharmacists did. Consider the fact that it would have taken around four times as long to refuse the script as it would to have dispensed the script for which the Pharmacist received little or no remuneration.

    What is also important is that they documented the clinical intervention which was then used in the code of conduct hearing.

    These examples show why Pharmacists need to be compensated for clinical interventions not associated with the supply of a medication. Where is Pharmacy leadership on this issue?

    PSA and PGA where are you??

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