KEY POINTS:
A Palmerston North pharmacist whose medicine mix-up led to the hospitalisation of the mother of a newborn baby has been ordered to pay $10,000.
John Morrison was fined $5000 for professional misconduct and ordered to pay $5000 costs when he appeared before the Health Practitioners Disciplinary Tribunal in Wellington today.
The tribunal also recommended that Mr Morrison undertake a Pharmacy Council competency review.
Mr Morrison was employed at City Health Pharmacy in Palmerston North when the dispensing error occurred in August 2006.
Two previous dispensing errors had occurred at the pharmacy, but neither of these involved Mr Morrison, it was stressed today.
He was not employed at the pharmacy in February 2006 when two-year-old Emma Leader was given an almost lethal dose of an anti-psychotic drug instead of the intended cough medicine.
Nor was he involved in June 2006 when a nine-week-old baby was given a dose of gastric reflux medicine that was five times too high.
Both these earlier errors were being investigated when Mr Morrison's own error was made and it was a difficult time at the pharmacy, his lawyer Alistair Darroch said.
"It's fair to say there was real pressure on all the staff at that stage."
In this case a woman stopped at the pharmacy with her newborn baby on her way home from hospital after giving birth, Health and Disability Commission director of proceedings Theo Baker told the tribunal.
She brought in a prescription for an iron supplement and for the blood pressure medicine Labetalol.
Two technicians misread the prescription as being for Largactil, which is used to treat schizophrenia and other psychoses.
Mr Morrison, the supervising pharmacist, was responsible for the final check before dispensing the drugs but did not pick up on the error.
He did notice the dose was high and talked to the client about it.
She told him she was taking blood pressure medicine and discussed the number of pills she was taking while in hospital.
Mr Morrison checked the prescription and incorrectly dispensed the Largactil.
He did not discuss with her the risks of taking Largactil while breastfeeding, despite the fact she was holding her baby and also purchased cream used while breastfeeding and two baby pacifiers.
Neither did he point out that the drug should not be taken with iron, although she had been prescribed iron supplements at the same time.
After taking the medicine the woman began to feel strange, became very sleepy, shaky and was slurring her words.
She was admitted to hospital where the error was discovered. She stayed in hospital overnight with an extreme Largactil overdose and was unable to breastfeed her baby for 30 hours.
When notified about the error the following day, Mr Morrison began a report on the incident, but this was not completed. He tried to visit the patient but she was not home. He did not immediately advise the pharmacy owner of the error.
He later apologised to the woman and gave her a letter of apology.
Mr Morrison was devastated by the error.
Mr Darroch said it was a one-off error and Mr Morrison's first in an unblemished career of more than 20 years.
In hindsight he accepted the prescription was legible, despite it being misread by himself and the two technicians.
He accepted that he missed clues which were available and that his actions would amount to professional misconduct.
The mistake had had a major impact on Mr Morrison, Mr Darroch said.
"This has really rocked his professional life".
His confidence had been affected and he had undergone counselling.
Mr Darroch argued that Mr Morrison's personal circumstances made it appropriate to suppress his name.
The incident had had a significant impact, and it would be inevitable his name would become associated with City Health Pharmacy, despite his not being involved in any way in the previous two high profile errors which had attracted wide publicity.
Tribunal chairman Bruce Corkill said after much consideration name suppression would not be granted.
He said the tribunal had fashioned an outcome with a rehabilitative focus and publication of Mr Morrison's name would not compromise this.
"The tribunal expects there will be some positive outcomes as far as this is concerned for Mr Morrison."
A disciplinary sanction was necessary for the protection of the public and to maintain professional standards.
Mr Corkill said it was clear Mr Morrison was very committed to his profession and the tribunal hoped he could now "move on".
- NZPA
