Pharmacists Handed Out Wrong Meds Because “Too Busy” Then Given Name Suppression


Effexor, can YOU spot the difference? Ever thought of becoming a pharmacist in NZ?

Patients in New Zealand  never get to know the names of the pharmacies that hand out incorrect medicines to patients, nor are they likely to know just how many chemists stuff-up their meds on a regular basis. Here’s one example.

A series of errors by two pharmacists saw a woman handed out the wrong drugs, double doses and incorrectly labelled medication five times in less than six months. The mistakes were detailed in a Health and Disability Commission finding released on Monday. source

The woman was prescribed Effexor-XR 37.5mg capsules to treat depression and anxiety. However, her pharmacist gave her double the dosage. She was then prescribed 40 mg nadolol to treat high blood pressure, but was given 40 mg propranolol instead which interacted with rizatriptan she’d been taking for headaches.

Ms A noticed the change in colour of her tablets and asked the pharmacist about the issue, who was “unable to recall how the error had occurred”, the report said. Later that year, Ms A returned to the pharmacy three times and was dispensed the correct medication – but with the wrong dosage instructions on the label.

The patient was precribed Konsyl-D powder (a laxative, to be taken with water) by her gastroenterologist, but the pharmacist didn’t label the container with the complete dosage instructions. Her doctor wrote her a repeat but the pharmacy put the wrong doctor’s name on the label. The pharmacy also messed up the patient’s repeat prescriptions

The two pharmacists also failed to fill out incident forms promptly, and

did not keep a record of amendments to the pharmacy’s records and failed to comply with professional standards, the commission found. “The number of errors relating to one consumer…is of significant concern,” the commission said.

“While each of these errors in isolation might appear relatively minor, any one of the errors could have had serious consequences in different circumstances.

“One of the pharmacists said the errors were made while the pharmacy was busy and he was in a hurry – a “poor explanation”, the commission found…

“The pharmacy was also found to be partly at fault, with the number of errors indicating a “systematic problem“. read the full report here

Surely a world class health system should be able to handle peak periods and hand out basic meds with some degree of precision? Everyone makes mistakes, but “systematic problems” and repeatedly messing up a patient’s meds is nothing short of negligence (Not that patients have any redress in-law in New Zealand, it’s all a bit of a gamble. She’ll be right)

For some reason, when these incidents are discovered, the pharmacists responsible are given anonymity and carry-on dispensing. It doesn’t exactly engender confidence, does it?

Update: the same situation is happening in hospitals too. This is from our Wiki page

In 2013  Eunice Richardson, 80, died after she was given Trimethoprim, a bacteriostatic antibiotic for a urinary tract infection when she was recovering from hip surgery. She was wearing a MedicAlert bracelet warning about her severe reaction to Trimethoprim, and each page of her documentation bore a large orange sticker warning about her allergy. “She was very particular about it and making sure that every doctor knew about it,” her husband Laurie Richardson said. She lost 60% of her skin to massive swollen blisters and died in pain in her husbands arms.  Her death prompted nothing more than an apology from the Canterbury District Health board chief executive David Meates. source

You may also be interested in

“Stick to the rules” A Woman was discovered dead in clinic bed after doctor gave her unapproved doses of ibogaine, then left her in the care of his assistant when he went on holiday…

In New Zealand it is not uncommon for doctors to prescribe unapproved medicines or approved medicines for unapproved purposes. HDC previously considered the use of an approved medicine for an unapproved purpose in a case relating to the prescription of ketamine to patients with treatment resistant depression. Recently another case has been concluded which involved the use of an unapproved medicine, ibogaine …

It was found that the doctor breached Right 6(1) and Right 7(6) of the Code of Health and Disability Services Consumers’ Rights .  It was also found that the doctor failed to monitor the woman adequately or keep appropriate records. source

Starting to see a trend emerging here?

Delayed diagnosis of cancer in primary care: what do our complaints tell us.

Over the last ten years, 243 general practitioners (in NZ) have been complained about in relation to a delayed diagnosis of cancer, with the number of complaints per year increasing significantly over that time.  While we note that this increase is consistent with general complaint trends, complaints about cancer misdiagnosis now comprise a significantly larger percentage of all complaints about general practitioners than was the case a decade ago.

Colorectal and lung cancers were the cancers most commonly at issue in the complaints, and the diagnostic delays were often lengthy. Comparatively, complaints about the delayed diagnosis of breast cancer were less common and involved shorter delays…

The factors leading to a delayed diagnosis most commonly identified by our expert clinical advisors related to:

  • the cancer presenting with non-specific or atypical symptoms;
  • poor communication with secondary care;
  • appropriate referrals not being made;
  • inappropriate reliance on negative test results; and
  • the GP failing to adequately take, review or consider relevant patient history… read on

The full report can be downloaded here.

  • Anthony Hill, Health and Disability CommissionerAssisted by Dr Katie Elkin, Associate Commissioner Legal and Strategic Relations and Natasha Davidson, Analyst – Research and Education  NZ Doctor, April 2015


3 thoughts on “Pharmacists Handed Out Wrong Meds Because “Too Busy” Then Given Name Suppression

  1. It’s all about money for them, nothing else. What else can you expect in a country where business types are assigned to certain groups of people. Look at who owns farmacies, etc etc. You have to be very careful here in NZ when selecting a GP, quite a few of them just don’t care at all. Just there for a quick buck. I changed a few GPS, now have one from UK, big difference. There needs to be an independent consumer website where comments can be made and these types of businesses avoided.

  2. These serious and sentinel types of events happen all the time, they’re a reflection of the sloppy attitude that New Zealand is infamous for. You may know it as “laid back” these pharmacists are so laid back they’re practically horizontal.

    I have some more examples for you, all from 2015.

    A Pharmacist dispensed cyclophosphamide (chemotherapy) instead of cyclosporine (anti-rejection) to a 79 year old man who’d had a kidney transplant. When the man pointed out his white tablets had mysteriously changed to pink the pharmacist altered the stock records to cover up his mistake, while telling the man they’d changed colour because the ‘stock had changed’
    Then there was the woman who’s IVF had to be abandoned because her pharmacist dispensed the wrong medication. She was prescribed oestradiol valerate (hormone replacement) but was given another hormone oestriol. Her doctor noticed the mistake when she began to bleed and she had to abandon her embryo transfer cycle's-ivf-abandoned-after-dispensing-error.aspx
    Or you could look at the 32 year old man that was given the wrong type of insulin by his pharmacist – Humulin NPH (medium-acting insulin) instead of Humulin 30/70 (a mixture of short and medium-acting insulin). His mother spotted the change in packaging and got the pharmacist to change it to the correct insulin the following day. The pharmacist failed to file an incident report and the same thing happened again a couple of months later, and again the pharmacist didn’t file an incident form.

    These incidents are very commonplace, patients have to have their wits about them and make sure they’re getting what their doctors prescribed. God knows how many inappropriate drugs get dispensed by laid-back busy chemists who never get named and shamed, hell they don’t even keep records. So professional.

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