A pharmacist faces possible disciplinary proceedings after approving the wrong medicine for a patient and later failing to tell the man exactly what had happened as soon as he found out.
The patient, aged 79 at the time, had had an organ transplant. He went to his pharmacy for medications, including a repeat prescription of white, anti-rejection capsules called cyclosporine, in October 2013.
By mistake, a pharmacy technician selected pink chemotherapy tablets called cyclophosphamide instead of the immune-suppression capsules. The pharmacist checked the medications and initialled the dispensing record.
On December 4, 2013 the patient went to the pharmacy for a regular test, after which he showed the pink tablets to the pharmacist and asked why they were different from his regular white capsules, according to a report made public today by Deputy Health and Disability Commissioner Theo Baker.
"I explained [to the patient]," the pharmacist told Ms Baker's investigation, "that he had been given a discontinued product and that he should immediately start back on his cyclosporine capsules which he had new stocks of from his November repeat dispensing at home and to discontinue these [cyclophosphamide] tablets."
The pharmacist said he told the patient this because he did not want to alarm him. He was confident the patient was not suffering any side effects.
The patient is thought to have taken up to 45 of the incorrect tablets but after the mistake was uncovered, he was given tests which, he told the pharmacy owner, had returned normal results.
After the pharmacist became aware of the error, on December 4, 2013, he altered the stock record to reflect both the absence of the chemotherapy - "to ensure it was replaced," he said - and the presence of one unit of the immune-suppression drugs.
It was not until December 6, two days after the patient had queried the pink tablets, that the pharmacist disclosed the error. He did so only after the patient had taken up the query with the pharmacy owner and after the owner in turn questioned the pharmacist.
The pharmacist offered to resign from the pharmacy. Ms Baker said he had breached the code of patients' rights and she has referred him to the commissioner's prosecutor for a decision on whether to take him to the Health Practitioners Disciplinary Tribunal.
She said the patient was placed at "significant risk of harm" because of the risk of toxicity from the chemotherapy and from not taking the immune-suppression drugs.
Ms Baker criticised the pharmacist for not adequately checking the medication when it was being dispensed, for failing to disclose the error to the patient at the first opportunity and for failing to report the incident at the time.
She said consumers had the right to know what had happened to them when an error had occurred.
The pharmacist said he had intended to inform the owner of the error, but became distracted and did not do so. He also said he wanted to assemble all the facts first, to avoid conflict with the owner.
Ms Baker rejected both of those arguments.
The pharmacist and the pharmacy's owner have apologised to the patient.
Ms Baker said the owner had notified the Pharmacy Council, which had concluded there were no concerns with the pharmacist's competence.
"The Council considered that the error was a one-off dispensing error, but that the way [the pharmacist] handled the error was 'well below the accepted standard'."