Panel hearing summary 2013.0163

Decision of the Pharmacy Board of Australia

Performance and Professional Standards panel

Jurisdiction: Western Australia
Date of Hearing: 7 May 2013
Date of Decision: 7 May 2013

Classification of Notification:

Pharmacy/medication: inappropriate, unlawful or inaccurate dispensing

Offence: drugs and poisons offence

Allegations

The Pharmacy Board of Australia alleged that a pharmacist behaved in a way that constituted unsatisfactory professional performance under section 191(1)(b)(i) of the National Law in that they:

1. made a dispensing error as a result of failing to:
   1. check the label details against the medication package 
   2. use a barcode scanner when dispensing the medication 
   3. count, alternatively, miscount, the remaining stock to cross-check the amount dispensed 
   4. perform a final check of the dispensed medication against the prescription and 
   5. counsel the customer collecting the medication.
2. failed to create a record, alternatively, an adequate record, of the dispensing incident in accordance with the Board’s Guidelines for dispensing of medicines.
3. failed to:
   1. ensure that the pharmacy’s Register of Drugs of Addiction Used and Received was maintained in such a way that at any time the amount of each drug of addiction supplied or kept was clearly apparent under section 44(3) of the Poisons Regulations 1965; and 
   2. make an inventory of drugs of addiction held in stock and to record the inventory in the Pharmacy’s Register at intervals of not more than one month under section 45 of the Regulations.

Finding

The panel found that the practitioner had behaved in a way that constituted unsatisfactory professional performance under section 191(1)(b)(i) of the National Law by making a dispensing error as a result of failing to:

1. check the label details against the medication package 
2. use a barcode scanner when dispensing the medication and 
3. perform a final check of the dispensed medication against the prescription.

The panel also found that the practitioner had behaved in a way that constituted unsatisfactory professional performance under section 191(1)(b)(i) of the National Law in failing to:

1. ensure that the pharmacy’s Register was maintained in such a way that at any time the amount of each drug of addiction supplied or kept was clearly apparent under section 44(3) of the Regulations and 
2. make an inventory of drugs of addiction held in stock and to record the inventory in the pharmacy’s Register at intervals of not more than one month under section 45 of the Regulations.

Given the practitioner’s uncontested evidence that a record of the dispensing incident was made, the allegation that the practitioner failed to keep such a record could not be substantiated.

The panel recommended, however, that, in future, the practitioner should ensure that they kept a personal copy of any such incident records and make an entry on the affected patient’s record.

Determination

The panel considered that the practitioner’s failure to adhere to good dispensing guidelines in this case was particularly serious, given that the medication dispensed was a Schedule 8 controlled substance.

The panel was also extremely concerned that the pharmacy’s Register did not reconcile for a number of months as a result of this incident and a previously omitted entry.

As the proprietor of the pharmacy, it was the practitioner’s responsibility to ensure the accuracy of the Register by complying with their legislative obligation to audit it on a monthly basis.

The panel reprimanded the pharmacists, given the seriousness of the deficiencies in their performance. The reprimand is to remain on the register of practitioners for five years.