A pharmacy mistakenly dispensed zinc capsules instead of sodium bicarbonate for a boy with a kidney disorder.
Deputy health and disability commissioner Rose Wall, in a decision published today, criticised the pharmacy for failing to ensure all its staff complied with its policies, and says a pharmacist failed to adequately check the dispensing of the boy's prescription.
The boy has epilepsy and the kidney disorder Fanconi's syndrome, in which glucose and other substances are not absorbed normally.
To treat the kidney condition he had been taking sodium bicarbonate.
The person dispensing the boy's prescription for sodium bicarbonate -- who failed to initial the prescription and so couldn't be identified by the pharmacy -- dispensed zinc capsules instead.