‘Travesty’: Chemist’s 17 problems but zero penalty

THE Pharmacy Board of Australia has refused to discipline two pharmacists who admitted negligently overdosing an elderly male heart patient, instead saying one chemist had "shown insight into his performance".

The error, in which the Brisbane man was issued a double dose of his morning medication for up to three months, led to calls for mandatory reporting of dispensing errors.

But the pharmacy board, which regulates the profession and sets annual registration fees, ruled no adverse findings in the dosage bungle.

The man, taking the drug metoprolol to control blood pressure after having triple bypass heart surgery, received his four seven-day dosages from Chemist Warehouse in a dose administration aid, designed to help people take medication according to a doctor's prescription.

According to the findings, he had been receiving the medication from the Carseldine store since January but over a few months had been feeling light-headed, fatigued and unsteady.

He fell over three times, once falling into a gully and narrowly missing a rock. He did his own research, checked the packaging and realised he was being given the wrong amount in the morning and the correct dosage at night.

The man complained to the Office of the Health Ombudsman and the matter was then examined by the pharmacy board.

In a written response to the ombudsman the chemist said it was a "regrettable incident" and listed 17 changes that had been made including the requirement of a packing log and a second pharmacist conducting checks.

The pharmacy board found the senior chemist had "shown insight into his performance" and taken steps to remedy future mistakes. It found the packer's workplace had taken "appropriate steps to mitigate the error reoccurring".

The Brisbane man said its decision was "outrageous" and a "travesty".

"It only took only a few days of making my complaint for Chemist Warehouse to order sweeping changes, 17 in total, in the way it dispenses and checks medications," he said.

"It took six months and a mountain of correspondence since December 2019 with the Office of Health Ombudsman, the Australian Health Practitioner Regulation Agency, the National Health Practitioner Ombudsman and Privacy Commissioner and the Pharmacy Board, for the board to give its final no-appeal decision".

The man said in a case in 2012 the board made a finding of unprofessional conduct against a pharmacist after she dispensed the wrong medication to a kidney transplant patient.

A Pharmacy Board of Australia spokeswoman did not answer a number of questions about the Brisbane man's case however said all information was considered before the decision was made.

Originally published as 'Travesty': Chemist's 17 problems but zero penalty