Australian Health Practitioner Regulation Agency - Panel hearing summary 2012.0129
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Panel hearing summary 2012.0129

Decision of the Medical Board of Australia

Performance and Professional Standards panel

Jurisdiction: Victoria
Date of Hearing: 19 July 2012
Date of Decision: 16 August 2012

Classification of Notification:

Pharmacy/Medication – Inappropriate administration

Other clinical care issue


It was alleged that the doctor failed to exercise care in administering an injection to a patient and behaved in a way that constituted unprofessional conduct.

The patient had presented to the doctor with symptoms of hay fever and was prescribed Kenacort A 10 by injection. As instructed by the doctor, the patient had the prescription filled by a pharmacist and returned to the doctor for them to administer it. The medication had been incorrectly dispensed. It was alleged that the doctor had failed to check the box label or ampoule label to ensure the correctness of the medication before administering it to the patient. As a result the patient experienced severe side effects and prolonged physical and psychological suffering for more than six months.


The panel found that the doctor had behaved in a way that constituted unprofessional conduct, namely, conduct that is of a lesser standard than might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers.

The panel found that the doctor had intended to administer Kenacort to the patient but had administered three ampoules of Modecate in error. The doctor had noticed that the contents of the ampoules looked oily in appearance while normally the intended injections were milky white. While the doctor telephoned the pharmacist and enquired about the difference in appearance of ampoules and was instructed that the difference was due to a change in manufacturer, the doctor had failed to check the box label or ampoule label with the dispensing label before giving the injection.

Although the doctor was not responsible for any dispensing error, they were responsible for checking the details on the box and ampoules before administering the injection.

The doctor admitted the mistake and took appropriate measures to explain the error to the patient and follow up on the patient’s progress. The doctor also made changes to their practice to minimise the risk of recurrence.


The panel cautioned the doctor to exercise appropriate care in administering an injection.

Page reviewed 17/04/2014