A Canberra pharmacist who oversaw supply of the wrong medication to a kidney transplant patient has had a finding of unprofessional conduct made against her, but has argued that the pharmacy she worked for had inadequate protocols to detect such errors.
Mandy Wang was the sole pharmacist on duty in the dispensary at the Chemist Warehouse in Phillip when the wife of "Customer A" came in to fill her husband's script.
Instead of the diuretic Lasix at a dosage of 250mg twice daily, Customer A's wife alleged she was supplied with the heart rate-slowing medication Digoxin and instructions to take the 250mcg dose twice daily.
Six days later, on May 20, 2012, Customer A began to vomit and have diarrhoea. His symptoms did not improve, so on May 25 his wife took him to the emergency department at the Canberra Hospital.
He was diagnosed with Digoxin toxicity and doctors administered him with the antidote. The amount of medication he had taken was four times the recommended dose for a patient with renal impairment, Customer A's wife alleged in her complaint to the Australian Health Practitioner Regulation Agency.
The drug had a "detrimental impact" on his kidney functioning and "brought forward the need to begin dialysis", she alleged.
As a result of taking the wrong medication, Customer A took two weeks away from work on sick leave. He returned to work part-time on June 4 and began dialysis on June 6.
In response to the allegations, Ms Wang, who had been registered as a pharmacist for about a month at the time, said she had been dispensing alone in a very busy environment.
She said she did not know what happened specifically with Customer A's prescription but believed that after the script was dispensed by dispensary assistant Shelby Clark, somebody handed the medication to Customer A's wife without it being checked by a pharmacist.
While the script was not placed in the "script checking area", Ms Wang said she recalls Shelby Clark telling her there was a script ready to be checked when she was free.
Ms Wang said she regretted the error and apologised to Customer A's wife and sent flowers to their home. She also believed the pharmacy had inadequate protocols to detect dispensing errors and said the dispensary at the pharmacy was at times "chaotic".
Ms Wang and the Pharmacy Board of Australia agreed that Ms Wang's behaviour amounted to unprofessional conduct.
She was formally reprimanded and a condition to undertake and pay for an Ethics and Dispensing Pharmacy Practice course was imposed on her registration as a pharmacist.
The ACT Civil and Administrative Tribunal made orders giving effect to the agreement between Ms Wang and the Pharmacy Board.
The tribunal noted Ms Wang's remorse and that the risk of her "repeating the conduct is very small".
As a result of the wrong medicine being dispensed, the pharmacy introduced new procedures that required the pharmacist to print their initials on all medications before they were handed to a customer and that all staff place completed scripts in one designated script checking area.