By Joshua Lafoai

A report into a prescription pills dispensing error is a wake-up call for the nation's pharmacies, the Health and Disability Commissioner (HDC) says.

The report, released yesterday by deputy commissioner Meenal Duggal, found a pharmacist failed to provide services in accordance with professional standards, and breached the Code of Health and Disability Services Consumers' Rights.

The complaint was lodged by a patient who was given a three-month supply of Ferrograd F in 2015. However the drugs were just a month away from their expiration date.


On October 14 of that year, the complainant returned to the pharmacy and filled another prescription. This time it included another three months' supply of Ferrograd F and four tablets of mercaptopurine 50mg. But instead of giving mercaptopurine, the pharmacist wrongly gave the patient cabergoline.

In early January 2016, the patient realized the Ferrograd F she had bought from the pharmacy had expired in June the previous year. She returned the pills and received a replacement prescription.

"The pharmacy's failure to ensure that the medications in its stock had appropriate expiry dates led to [Patient B] receiving expired and short-dated Ferrograd F," the report said.

"Accordingly, the pharmacy did not provide services to [Patient B] with reasonable care and skill, and breached Right 4(1) of the Code."

Duggal recommended the pharmacist arrange for an assessment through the New Zealand College of Pharmacists regarding her processing of prescriptions and her processes for dispensing and checking medications, and that she write an apology to the complainant.

Duggal also recommended the pharmacy conduct a compliance audit and provide a written apology.

The director of the pharmacy told HDC it had run through various scenarios on what may have led to the error.

"An incorrect brand name was written on the prescription by the person who dispensed the prescription," she said.

"Both medicines are in a small brown glass bottle, the products are stored in different areas of the dispensary (ordered generically); however, because the bottles look similar the cabergoline bottle may have been put incorrectly on the shelf in the tray that the mercaptopurine tablets are stored in," she added.

The pescriptions were dispensed during the peak of rush hour.

Pharmaceutical expert Paul Vester told HDC the dispensing mix-up was a serious error.

"Regardless of work load and distractions it is still within the expected scope of her practice as pharmacist to avoid such a mistake," Vester said.

Duggal said that the pharmacy has since introduced a green dot system to mark short-dated stock.