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Doctor, pharmacists 'breached health code'

NZ Newswire logoNZ Newswire 30/01/2017

The Health and Disability Commissioner has criticised a doctor and two pharmacists after medication ten times the proper dose was given to a toddler.

After being treated in hospital for bladder issues, the three-year-old was prescribed an appropriate dose of 2mg oxybutynin by the paediatric registrar but "oxybutynin 20mg" three times daily for ten days was written down.

The first pharmacist noticed the dose seemed high but did not question it, while the second pharmacist gave it to the girl's mother but did not discuss the medication with her.

The girl experienced side effects and was taken to hospital again.

In a report released on Tuesday Commissioner Anthony Hill is critical that the paediatric registrar did not check the prescriptions.

He also found that the first pharmacist failed to take steps to contact the prescriber when she noticed the dose seemed high; and that the second pharmacist did not check the prescription, and didn't question it when handing it to the mother.

Mr Hill found that there was non-compliance with the operating procedure by more than one staff member within the pharmacy, which played a part.

Mr Hill found the registrar, the two pharmacists and the pharmacy were in breach of the Code of Health and Disability Services Consumers' Rights.

He has made a number of recommendations including that the pharmacy undertake two audits of compliance with its dispensing prescription standard operating procedure, using this case as an case study for educating future employees of the pharmacy.

The commissioner also recommended that the Pharmacy Council of New Zealand consider whether a review of the first pharmacist's competence is warranted.

Mr Hill suggests the paediatric registrar, the two pharmacists and the pharmacy each provide a written apology to the girl's parents.

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