A Dunedin man died after a series of prescription errors led to him taking a daily dose of a drug meant to be taken weekly.
Kenneth Douglas, 72, was accidentally prescribed a potentially lethal dose of methotrexate in May 2012 to treat rheumatoid arthritis, coroner Christopher Devonport said in his findings, released today.
He died a month later from a gastrointestinal haemorrhage caused by the overdose of the drug.
He had been suffering from the condition for 20 years and had been taking the drug in a weekly dose for several years.
His doctor, Anne-Marie Tangney, lowered his dose in May 2012 but accidentally wrote on the prescription to take it daily rather than weekly, Devonport said.
This error was not picked up by the dispenser, Unichem South City, when Douglas filled the prescription, Devonport said.
In total there were eight opportunities for the pharmacy to find the prescription error, he said.
The pharmacy did not have enough tablets to fill the prescription and asked him to come back later to fill in the balance, and that, along with several other security checks, should have alerted the staff to the error, he said.
"Douglas' tragic death may have been prevented if the pharmacy had picked up Dr Tangney's clinical error," Devonport said.
"Even with the prescription written wrongly by Dr Tangney, there were critical points where the clinical mistake could and should have been picked up by the pharmacy."
The doctor, the pharmacy and the appropriate medical councils had all taken appropriate steps to ensure such as error, and tragic death, does not happen again, Devonport said.
Devonport also made recommendations including that doctors specify what day of the week a weekly medication needs to be taken in the hope that it would provide a further fail-safe.
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