Australian Health Practitioner Regulation Agency - Panel hearing summary 2011.0009
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Panel hearing summary 2011.0009

Decision of the Pharmacy Board of Australia

Performance and Professional Standards Panel

Jurisdiction: Victoria

Date of Hearing: 27 June 2011

Date of Decision: 14 July 2011

Classification of Notification:

Pharmacy/Medication - Inappropriate, unlawful or inaccurate dispensing

The pharmacist gave incorrect medication to the patient resulting in the patient being hospitalised for four days.


The pharmacist faced allegations that the wrong drug was administered, namely Coversyl (for blood pressure) rather than Coumadin 5mg (a blood thinner) and that the pharmacist did not counsel the patient when administering the medication.


The Panel found that the two allegations were made out and that the pharmacist dispensed Coversyl 5mg tablets to the patient, which were labelled as Coumadin 5mg, did not counsel the patient when giving her the medication and did not exercise the care or the judgement that a pharmacist with her experience should have had in the circumstances. The pharmacist did not comply with the Board’s Guidelines for dispensing of medicines, which advise that a pharmacist should always scan the medication being dispensed and when counselling the patient, check again that the correct medication is being dispensed.

On the basis of those findings, the Panel decided that the pharmacist behaved in a way that constituted unsatisfactory professional performance.


The Panel accepted that the pharmacist was remorseful, had apologised to the patient and put in place measures to prevent the error recurring. The Panel cautioned the pharmacist to take more care when dispensing medication and to practice according to the Guidelines for dispensing of medicines.

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Page reviewed 17/04/2014