The report found the man's GP and endocrinologist provided differing prescriptions, and his pharmacist failed to ensure he was provided the correct medication. Photo: RNZ
A man was admitted to hospital suffering episodes of fainting and dizzy spells after being wrongly overprescribed medication, the Health and Disability Commissioner has found.
The commissioner's report, released on Monday, says the error came during the midst of the Covid-19 pandemic causing strain in the health sector in May and June 2021.
The man's son told the commissioner his father began experiencing dizzy spells and several episodes of fainting or passing out, and went to the emergency department on 18 June 2021.
Deputy Health and Disability Commissioner Deborah James said the man's GP and endocrinologist provided differing prescriptions, and his pharmacist failed to ensure he was provided the correct medication.
On 26 March 2021, the man was reviewed by his endocrinologist and advised he would be changing from a 8mg daily dose of candesartan to a 4mg dose, along with discontinuing a dose of spironolactone for a 4mg dose of empagliflozin.
On 10 May, the man's pharmacist prepared his old prescription in a blister pack, but when she was provided his new handwritten prescription on 13 May, she supplied the man a month of loose 4mg candesartan, but still included the original dose of spironolactone.
The pharmacist told the commissioner she had been rushed on the day due to Covid-19 related stress, and she replaced the 8mg dosage with 4mg, but claims she was not made aware of any other changes.
On 25 May, the man was provided a new prescribed dosage by his doctor, which reverted the candesartan dose back to 8mg and 25mg of spironolactone, unaware of the changes made by the man's endocrinologist.
The man's next blister pack was then processed by the pharmacist on 31 May after being on hold for four days, consisting of the prescriptions from the endocrinologist and the doctor's new prescription.
She said this was because 31 May was "extra busy".
By 8 June, the man was being prescribed both 8mg and 4mg of candesartan in the same blister pack, alongside spironolactone.
Pharmacist Sharynne Fordyce, who was provided independent advice to the commissioner and had over 30 years experience in retail pharmacy, said several opportunities were missed to identify and fix the discrepancies.
The pharmacist and pharmacy accepted the findings of the report, including providing formal written apologies to the man.
The pharmacy had also since employed another part-time pharmacist to allow the pharmacist to reduce her hours.
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