Recently, a New Zealand boy was admitted to the hospital three times after he was provided a prescription that was 10 times stronger than prescribed by his physician. According to a local news report covering the error and the subsequent investigation, the boy suffers from cerebral palsy and is prescribed Baclofen, a muscle relaxer, to help him control his symptoms.
Evidently, the prescription was phoned in by the boy’s physician and picked up by his mother. She gave him the medication as directed, and as a result she had to take her son to the hospital three times with increased seizures, shortness of breath, and deep breathing. It was not until the third visit to the hospital that it was discovered that the reason for her son’s exacerbated symptoms was the dispensing error.
An investigation was initiated by a government oversight group to find out how this type of error could occur. The investigators discovered that there were two pharmacists on duty that day: a filling pharmacist and a checking pharmacist. According to the inspector, the performance of both pharmacists fell short of the duty they owed the child. The investigator explained that “maintaining a logical, safe and disciplined dispensing procedure, including assessing the efficacy and safety of medicine, are fundamental aspects of pharmacy practice.”