Pharmac dealing with problem of identical drug-packaging

Pharmac is working on a solution to concerns over identical packaging for an anti-nausea drug and an anaesthetic, medical director Peter Moodie said today.

The Government's drug buying agency was responding to reports yesterday that a potentially fatal anaesthetic had spent several months sitting on Christchurch Hospital drug trolleys beside anti-nausea drugs in identical bottles.

The situation was brought to the attention of the hospital's clinical directors three weeks ago.

Since then red stickers had been put on the anaesthetic bottles and the anti-nausea drug had been removed from all areas of the hospital.

Dr Moodie said today Pharmac had discussed the issue with drug manufacturer AstraZeneca who had indicated it would be no trouble "to change the colour of the writing on the ampoule".

Pharmac would also meet the College of Anaesthetists next Monday.

Concern over the packaging issue has been expressed by the Canterbury and Waikato district health boards.

Christchurch Hospital's intensive care unit clinical director, George Downward, said yesterday that in a moment of high pressure it was possible staff could misread bottles.

Dr Downward, chairman of the hospital's quality patient safety committee, said the issue was a problem in most of the country's hospitals.

The 21 DHBs were required to buy the products subsidised by Pharmac.

Dr Downward expected the removal of the anti-nausea drug from the wards to cost Canterbury District Health Board $500,000 this year because more expensive anti-nausea drugs would need to be used.

"You have to weigh up that cost versus the potential for injury," he said. "If someone dies in the next four to five years because of a mix-up... it is a matter of how you quantify that. I certainly can't say that wouldn't happen."

Dr Moodie said there were a number of other drugs in the same sort of ampoule as the anti-nausea drug metoclopramide and the anaesthetic suxamethonium causing concern in Christchurch.

"So it's not just the suxamethonium and metoclopramide -- it's an issue that needs to be discussed on a wider scale.

"I really don't want to minimise the risk of a system error with these sort of things but it's a problem that's been there for a long time. It's an issue we need to deal with in a calm and sensible way," he said.

Dr Moodie said yesterday that at least nine other drugs came in the same 2ml bottle, and at least half of New Zealand's hospitals had been using them for some time.

- NZPA