A pharmacy has been criticised after it mixed up a four-year-old's allergy medicine with antipsychotics, causing the young boy to be rushed to hospital.
The Health and Disability Commissioner in a report released on Monday found the unnamed pharmacy in breach of its code following the "dispensing error".
The boy had been prescribed liquid loratadine for hay fever by his GP and the medication was administered twice by the boy's parents on November 25 and 26, 2021.
Shortly after the boy took the medicine for the second time, he experienced an apparent severe allergic reaction and was admitted to the hospital.
A toxicology screening of the liquid medication identified the presence of the antipsychotic medication haloperidol.
In rare cases, haloperidol can cause serious allergic reactions (anaphylaxis) which can be life-threatening and require urgent medical care.
The dispensing pharmacy was made aware of the error, and they reviewed the incident including interviewing the staff members involved and outlining the actions taken as a result. MedSafe also conducted its own investigation into the matter.
MedSafe's investigation found that one of the workers added haloperidol into the loratadine dispensing bottle to make up a total of 200ml.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell, with the agreement of the Pharmacy, adopted the findings of the Medsafe report. She considered it more likely than not that the inadvertent addition of haloperidol to the loratadine dispensing bottle was a result of a "dispensing error at the pharmacy".
Dr Caldwell found the pharmacy in breach of Right 4(1) of the Code for failing to dispense liquid loratadine correctly.
"The pharmacy has an organisational responsibility to provide a reasonable standard of care to its consumers. In my opinion, the error represents a failure by the pharmacy to provide services with reasonable care and skill," she said.
Following Medsafe's investigation, the pharmacy made several changes, including getting new machinery to provide more accurate dispensing, increasing staffing levels and implementing a new process to ensure staff are aware of any brand changes and changes to medication positioning.
The pharmacy also made it a requirement for two people to check the medication during preparation and dispensing.
Dr Caldwell commended the pharmacy on the actions taken once it became aware of the incident, including openly disclosing to the boy's parents that the incident had occurred and that the pharmacy was investigating it, extending an apology, and undertaking an incident notification.
Further to the changes already made, Dr Caldwell recommended the pharmacy undertake an audit of dispensed liquid medications to determine whether these were checked by two people.
