Dose administration aid packaging errors made.
The Pharmacy Board of Australia (PBA) has said pharmacists need to exercise extra vigilance with drugs of a narrow therapeutic index, following several fatal incidents involving the drug methotrexate.
In its communiqué, the PBA said its Notifications Committee received notices in “recent months” of several medication incidents resulting in the death of patients where the medication was dispensed correctly but the resultant packaging of the drug into dose administration aids (DAA) such as Webster packs was incorrect and the packing was not detected by the releasing pharmacist.
In an encapsulation, the PBA said a prescription of methotrexate was dispensed correctly for packing into a DAA but incorrectly packed to be taken every day, in two separate weekly packs.
The packs were checked by two different pharmacists on consecutive weeks, both releasing them for patient use.
The patient was admitted to hospital with mouth ulcers where hospital staff picked up the error.
The patient died some days later and the death was referred to the Coroner’s Office, the PBA said.
The Coroner found the cause of death was immune system compromise, caused by the toxic effects of methotrexate dispensed and incorrectly packed by the pharmacists as daily instead of once weekly doses, the PBA said.
“This case underscores the Board’s concern when pharmacists dispense and subsequently pack into a DAA for later consumption by the patient, of drugs with a narrow therapeutic index.”
“Extra vigilance is required to be exercised by pharmacists with these drugs.”
For more, see Monday’s Pharmacy Daily.
