A pharmacy mistakenly dispensed zinc capsules instead of sodium bicarbonate for a boy with a kidney disorder.

Deputy health and disability commissioner Rose Wall, in a decision published today, criticised the pharmacy for failing to ensure all its staff complied with its policies, and says a pharmacist failed to adequately check the dispensing of the boy's prescription.

The boy has epilepsy and the kidney disorder Fanconi's syndrome, in which glucose and other substances are not absorbed normally.

To treat the kidney condition he had been taking sodium bicarbonate.


The person dispensing the boy's prescription for sodium bicarbonate -- who failed to initial the prescription and so couldn't be identified by the pharmacy -- dispensed zinc capsules instead.

The pharmacist opened the bottle as part of the checking process but sodium bicarbonate and the zinc capsules were similar in appearance and she did not notice the error. Nor did she notice the words "Zincaps", or "ZINC SUPPLEMENT" on the outside of the bottle.

In September 2014, the mother of the boy, who was then 8, started giving him the zinc capsules, thinking they were sodium bicarbonate.

When the boy suffered epileptic seizures -- unrelated to the zinc capsules -- and was admitted to hospital, a hospital pharmacist checked his actual medications against his prescriptions and noticed the error, notifying the ward doctor and the pharmacy.

The pharmacy has agreed to Ms Wall's recommendation to write an apology to the boy and his mother.