Pharmacist’s safety check failures led to baby’s overdose: commissioner

WELLINGTON: A 4weekold baby suffered a methadone overdose after a pharmacy failed to dispense their medication safely in June 2018.

A pharmacy technician accidentally mixed the baby’s colic medicine, omeprazole, with methadone, which went unnoticed by a pharmacist.

The pharmacist had left an unlabeled bottle containing methadone on the dispensary bench, and a pharmacy technician inadvertently used that bottle to prepare the omeprazole prescription for the baby.

Deputy health and disability commissioner Dr Vanessa Caldwell found the pharmacist failed to carry out the appropriate checks in the dispensing process, leading to the error.

‘‘I consider the ultimate responsibility for the dispensing error sat with the pharmacist. He held the responsibility to ensure the accurate dispensing of medicine, and should have double checked the dispensed medication,’’ Dr Caldwell said.

Dr Caldwell said in failing to dispense the omeprazole in a safe and appropriate way, and by failing to check the final product, the pharmacist did not provide services to the baby in a manner consistent with professional standards and competent pharmacist practice.

The deputy commissioner’s office has said this was a distressing incident but could have had the worst outcome if the baby’s mother had not intervened as early as she did.

After the mother gave the baby a dose of omeprazole the baby started breathing abnormally and became unresponsive. The baby was taken to hospital by ambulance and later treated in ICU.

Dr Caldwell was critical of the pharmacist’s management of the dispensing error, noting a delay took place of 90 minutes120 minutes between the discovery of the error and that the first attempt to contact the baby’s mother was inadequate.

She said several errors in the pharmacy’s dispensing practice amounted to a service delivery failure for which the pharmacy was responsible.

The pharmacist has since expressed regret and their pharmacy has implemented a number of changes to their operation.

Dr Caldwell has referred the pharmacist to the director of proceedings to whether any action should be taken.

She has also recommended the pharmacy technician complete the improving accuracy and selfchecking workbook provided by the Pharmaceutical Society of New Zealand.

‘‘As a registered pharmacist, he was responsible for ensuring he provided services of an appropriate standard,’’ Dr Caldwell said. — RNZ