A Christchurch pharmacist put a customer at risk after failing to admit he had been given the wrong drug, a tribunal has found.
The Health Practitioners Disciplinary Tribunal censured and fined “qualified, experienced and capable pharmacist” Terrence Zelcer thousands of dollars for professional misconduct.
Zelcer, a pharmacist of more than 30 years with an unblemished record, discovered in December 2013 the wrong drug had been given to a patient in October the same year.
The tribunal was told it was a “particularly vulnerable” 79-year-old patient with multiple health issues.
The customer had had a kidney transplant in 1999 and had been taking, among other medications, an immunosuppressant to prevent organ rejection.
When the patient visited the pharmacy for a refill of this medication in October 2013, a pharmacy technician gave him another drug used in combination chemotherapy regimes by mistake. This drug can lead to an increased risk of serious infection and require supervision of physicians fully trained in the use of such drugs.
The error also put the patient at risk of kidney rejection because he would not take his correct medication.
Zelcer failed to notice the error.
A couple of months later, the customer came for a routine blood test and asked Zelcer why the pills prescribed in October were different to his normal ones. By that time, he had taken 35 tablets of the wrong drug and missed out on his normal treatment for two and a half weeks.
When Zelcer realised the error, he “misled” the patient, telling him the drug he had been given was discontinued and he should resume taking his other tablets instead.
He did not tell him he had been given the wrong drug and did not inform his GP or his pharmacy manager. He did not ask the customer how many tablets he had taken.
Zelcer placed the bottle containing the wrong drug, left by the patient, into the pharmacy’s returned medicines bag outside.
Two days later, the patient came back to the pharmacy and spoke with the manager in private about the issue.
Zelcer then admitted what happened when confronted by his manager.
The patient’s GP was informed and he had to get urgent blood tests, which turned out to be fine.
Zelcer told his boss he intended to mention the error but it had been “at the back of his mind” and he had been “distracted” by a high volume of work.
The tribunal found Zelcer’s “failed to take appropriate steps to minimise potential harm to [his] patient”, but there was not enough evidence that Zelcer had intended to “cover-up” the error.
Zelcer accepted his professional misconduct and resigned from the pharmacy. He now works as a locum in other Christchurch pharmacies.
He wrote a formal letter of apology to the patient and consulted a psychologist
He was “deeply regretful of his actions” and “held in highest regard by current employers and colleagues”, the decision said.