A second incident just under a month later saw a man with an enlarged prostate prescribed tamulosin hydrochloride. When filling the prescription, the pharmacist incorrectly selected tacrolimis, an immunosuppressant. The pharmacist performed a final check, but failed to identify the mistake.
In a complaint to the Pharmacy Council, the man said he asked why the medication looked different than usual but was told by the person handing him the drugs that it would perform the same function. He took the medication for five weeks.
When the error was identified when he went to fill a repeat, the pharmacy manager apologised and advised the man to visit his GP as soon as possible.
On the incident form, possible causes of the error were listed as “interruptions by customers” and “similar names of the medications”.
A third detailed incident surrounded incorrect instructions listed on a prescription. A patient was prescribed colchicine, a gout medication, twice a day for six months while he became established on another long-term gout medication.
The prescription stated it should be taken once a day for three months, and after four days, a three-day break should be taken. Regardless, the pharmacist told the man he should ignore the warnings on the label if advised otherwise by his doctor.
Following notification of the three complaints, the commissioner sought figures from the pharmacy as to how many errors had been made between August 2019 and August 2020.
Of the 51,695 prescriptions, there were 22 recorded dispensing errors. A junior pharmacist was responsible for 16 errors, while the pharmacy manager was responsible for six.
The errors included mixing up medications, dispensing incorrect strengths and or repeats, and unclear instructions on labels.
The junior pharmacist, who is no longer with the supermarket, told the commissioner that from August 2019 she made multiple errors. She had been going through a number of personal issues, and the errors created a “flow-on effect” where after making a mistake, she became anxious to prove herself and made further errors. She was “very remorseful” about the errors.
The Pharmacy Council investigated, concluding she would be better suited to a smaller pharmacy, with stronger supports in place. It chose to take no further action.
The pharmacy manager told the commissioner that errors she made “were not characteristic of my usual practice”. Many of the errors occurred during Covid-19 lockdown when customer demand was high and staff were mentally exhausted.
The company that owns the pharmacy, whose parent company is Woolworths Australia, told the commissioner that they recognised there was room for improvement at the pharmacy.
It noted no issues had been identified during Ministry of Health audits, but accepted the issues identified showed the pharmacists involved were not complying fully with standard operating procedures.
“We feel that the reality is that, however comprehensive and regularly reviewed our policies and procedures are, on rare occasions human error can unfortunately occur.”
Assessing the facts, the commissioner concluded that the pharmacist’s mistakes were a “severe departure from accepted practice” and constituted a breach of the health and disability code.
“While there were a number of systemic and mitigating factors that influenced Ms B’s practice at the time of these events, Ms B had a professional responsibility to ensure that the services she provided were of an appropriate standard.”
But while the pharmacist was responsible for the errors, the company also has a duty to ensure it provided services with reasonable care and skill, the commissioner said.
“In my view, the multiple incidents that occurred between August 2019 and August 2020, involving more than one staff member, brings into question the systems in place at the pharmacy for oversight and support of its staff to provide safe and accurate dispensing.”
She also raised concerns about staffing levels.
McDowell said simply contacting pharmacy staff was not sufficient, and the company should have been monitoring incident trends closely, regardless if they were actively reported by staff.
She noted that the Countdown Pharmacy support office, together with the pharmacy directors, now undertake regular site visits to check compliance.
McDowell recommended the pharmacy provide her with a report of all incidents in the six months preceding today’s determination, as well as a review of the effectiveness of a new dispensing robot.
She also recommended Countdown use an anonymised version of the decision to provide education to staff across sites nationwide, and add a review date to the pharmacy’s standard operating procedures.
In a statement, Countdown said they worked with the commissioner as part of her investigation, and deeply regret the incidents identified.
“When these issues were raised with us by the HDC, we undertook our own internal review and made a number of changes to our systems and store operating procedures to ensure accuracy and increased support for our Bayfair Pharmacy team. These changes address all the recommendations made in the report,” the statement said.
“We continue to regularly self-audit all Countdown Pharmacies across New Zealand to ensure patient care is maintained at the highest levels.”
