
A 4-week-old baby with a croup stopped breathing, turned blue and went floppy after being given medicine that was five times the dose it should have been.
The mother was slowly using a syringe to put the oral steroid Redipred into the side of her baby鈥檚 mouth when the newborn inhaled the last 0.5ml of the 4.5ml dose and stopped breathing. Her mother performed CPR and the baby began to breathe again, before being rushed to the emergency department.
The Deputy Health and Disability Commissioner has found in a decision released today that the baby had been given five times the prescribed dose of steroid, due to a pharmacist error.
Dr Vanessa Caldwell said the mother was given medication labelled with the incorrect dose for her baby, which resulted in 鈥渁n extremely serious situation鈥 which required resuscitation and hospitalisation.
On examination, the baby was well except for an 鈥渆jection systolic heart murmur鈥 and was discharged from hospital the following day, with the parents told to check with their GP/paediatrician regarding the murmur.
The mother told the commissioner the baby has recovered following intensive follow-up with a private paediatrician in the community team at the hospital and, while the 鈥渕edium-term outlook for her is good, there are still uncertainties about the longer-term effects鈥.
She said it was the pharmacist鈥檚 job was to check the prescription.
鈥淗owever, having admitted to not checking it, signing it as checked and then stating it was checked but not identifying the error was 鈥榬eckless and unreasonable鈥,鈥 the mother said.
鈥淭his should never have happened, and it must never happen again.鈥
What went wrong
According to the findings, the dispensed medication dose on the box given to the mother should have read 0.9ml but instead read 4.5ml.
When the mother got to the hospital, she informed the triage nurse that she had administered 4.5ml of Redipred as per the label instructions from the pharmacy.
Initially, staff at the hospital inferred the mother had misread the dose on the label of the medication and, as a result, she believed she鈥檇 made a mistake that caused her baby to stop breathing.
She then thought it might have been an error the GP had made, but it was soon discovered the mistake was made at the pharmacy.
The locum pharmacist, referred to as Ms B in the decision, admitted there was an error 鈥 she had not checked the label on the Redipred box against the prescription from the GP.
The initial mistake happened when a trainee pharmacy technician 鈥渕isread鈥 4.5mg on the prescription from the baby鈥檚 GP as 4.5ml, and typed the prescription quickly into the system before printing the label for the pharmacist to check.
But, it was the pharmacist who was meant to complete the final check of the medication against the prescription.
Ms B, who had been a pharmacist for nearly 10 years, acknowledged she failed to identify the error in the stated dosage when she did the final check.
Dr Caldwell said while she couldn鈥檛 determine exactly what was discussed between the pharmacist and the mother when the medication was handed over, it was clear the pharmacist knew it was for a 4-week-old baby and necessary checks should have been done.
鈥淲hile this is essential for any medication, it was especially important in this case given that the patient was a 4-week-old infant who would be particularly vulnerable to even the most minor adjustments to medication doses.鈥
The pharmacist signed the prescription, stating it had been 鈥渃hecked鈥 against the label of the prescription, but Dr Caldwell found that if she had followed the pharmacy guidelines when she did this, the dosage error would have been caught.
鈥淢s B also failed to check for clinical appropriateness of the dose of the medication,鈥 she said.
鈥淔or this reason, I do not accept that a proper 鈥榗heck鈥 was carried out by Ms B in line with the pharmacy鈥檚 standard operating procedures and the Pharmacy Council of New Zealand鈥檚 Competence Standards, and I am critical of this.鈥
Ms B also acknowledged that although she checked the baby鈥檚 address and identity, she did not give any counselling to the mother around how to give the medication.
鈥淭his, along with the failure to check [the baby鈥檚] weight, was another missed opportunity to identify the dosage error. I am critical of this.鈥
Dr Caldwell was also critical of the pharmacist鈥檚 explanation for why she failed to check it.
鈥淪he considered that one of the factors was the slow pace of the pharmacy, and that because the script was straightforward, she may not have given it the attention it required,鈥 Dr Caldwell said.
鈥淚n my view, if the pharmacy was not busy, this would allow more time for attention to be given to a script, and I consider this not to be a relevant factor in the error.鈥
Dr Caldwell found the pharmacist had breached the Code of Health and Disability Services Consumers鈥 Rights by not checking the dispensed medication against the prescription, not spotting the error, and failing to advise the mother on how to administer the medication.
Concerns about communication
Following the incident, the pharmacist contacted the parents of the baby to check how she was doing.
However, Dr Caldwell had 鈥渃oncerns鈥 about the contact.
鈥淲hilst it is understandable that [the pharmacist] wanted to check on [the baby鈥檚] condition, clearly it was a stressful time for [the] family. I consider that they should have been given time to focus on [the baby鈥檚] care and recovery at the hospital without having [the pharmacist] contact them for updates or offers of assistance.鈥
The parents said the pharmacist had called them 鈥渇our times from multiple numbers鈥 and then offered to sit with the baby while the mother had a break and looked after her other children.
The mother told the HDC that she declined the offer, and told the pharmacist she did not have the capacity to speak to her.
She told the HDC that during the call, the pharmacist told her that on the day the incorrect dose was given, the pharmacy had been busy and short on staff, and she offered this as an explanation for the mistake.
The decision said the mother described feeling 鈥渁larmed鈥 and 鈥渄eeply uncomfortable鈥 during these conversations. She also felt they were 鈥榰nprofessional and inappropriate鈥.
The pharmacist鈥檚 lawyer said that she 鈥渘ever offered to sit with [Baby A] while [Mrs A] had a break. This clearly would not have been appropriate. She made a general offer of help. This was intended to be an offer of help in her role as a pharmacist. For example, to provide any further information which [Baby A鈥檚] treatment team might need from the Pharmacy.鈥
The pharmacist told HDC that she does not recall Mrs A saying that she did not want to be contacted further, and also denied telling her the mistake happened due to a busy pharmacy or understaffing.
However, Dr Caldwell found the pharmacist should have respected the request for no further contact and should have maintained appropriate professional boundaries.
鈥淚 am critical that this did not happen, and that Ms B continued to contact Mrs A.鈥
Recommendations
The pharmacist was told to provide a formal written apology to the baby鈥檚 parents for the breach.
Dr Caldwell noted the pharmacist had already completed recommended reading about both avoiding medication errors and about the importance of professional boundaries.
It was recommended she outline improvements she made to her practice as a result of this training, within three months of the HDC report.
The pharmacist also reviewed a best practice guide for avoiding medication errors in children, and had three months of mentoring, with a focus on paediatrics.
The trainee pharmacy technician was reminded of the importance of 鈥渟lowing down and being meticulous when inputting information from prescriptions into the computer system鈥.
She was also told to complete the Improving Accuracy and Self-Checking Workbook provided by the Pharmaceutical Society of New Zealand and outline any further changes made to her practice as a result of this training.
It was recommended the pharmacy undertake a random audit of the 鈥渙verall processing, dispensing, and checking of medication of 50 prescriptions over a one-month period鈥.
It also needed to do a yearly refresher training for staff, and review its induction programme to effectively train locum or temporary staff on its standard procedures.
It should also use this case as a basis for developing ongoing education/training on the dispensing process, managing dispensing errors, and dealing with customer complaints, for staff across all the pharmacy branches, including any new staff.
Hannah Bartlett is a Tauranga-based Open Justice reporter at 九一星空无限. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at 九一星空无限talk ZB.
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