Methotrexate NZ errors
September 3, 2014
A NUMBER of recommendations
have been suggested to ensure
methotrexate dispensing errors
in NZ do not occur, following the
death of Kenneth Douglas.
Coroner Christopher Devonport
said the patient’s GP had written
‘daily’ instead of ‘weekly’ on the
prescription and a report prepared
by NZ College of Pharmacists
executive board member Bernard
McKone reviewing the practices at
the dispensing pharmacy, Unichem
South City, Pharmacy, found a total
of eight opportunities for the error
to be picked up.
These included not confirming
Douglas’ details and checking
medical history, disregarding a
computer alert, failing to pick up
on the error when explaining the
medication to the patient and
when the patient was asked to
come back to fill the balance of the
prescription as the pharmacy did
not have enough tablets in store.
The coroner said even with the
prescription error, there were
critical points where the clinical
mistake “could and should” have
been picked up by pharmacy staff.
Recommendations included
that queries from pharmacists
should be communicated directly
to the prescriber while McKone
recommended that dispensing
SOPs across companies and
pharmacies be reviewed “urgently”
through an accredited process such
as a Ministry of Health audit, it said.
The Pharmacy Council of NZ
did not think a full review was
necessary but appointed a mentor
to the pharmacist who had made
the errors, and who was declared
competent in 2013, the report said.
It said the Council agreed that
pharmacists should activate
medication alerts on pharmacy
software where available, and the
Coroner said a reminder of this
could be made in the Council’s
communications to the profession.
The Council referred PD to the
Health and Disability Commissioner
regarding the number of
methotrexate incidents and a
spokesperson said they were
unsure whether a warning would
be sent out in its next newsletter.
A Health and Disability
Commissioner spokesperson said
an Official Information Act would
be required to collate information
about methotrexate complaints.
The Pharmaceutical Society of NZ
said it was unable to respond to
queries about whether it was aware
of other incidents or whether it
would advise pharmacists to be
extra vigilant.
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