Methotrexate deaths
June 16, 2014
THE Pharmacy Board of Australia
has said pharmacists need to
exercise extra vigilance with drugs
of a narrow therapeutic index
following several fatal incidents
involving the drug methotrexate.
In its communiqué, the Board
said its Notifications Committee
received notices in the “recent
months” of several medication
incidents resulting in the death
of patients where the medication
was dispensed correctly but the
resultant packaging of the drug into
dose administration aids (DAA) such
as Webster packs was incorrect and
the packing was not detected by
the releasing pharmacist.
In an encapsulation of the reports,
the PBA said the prescription
for methotrexate was correctly
dispensed for packing into a DAA,
prescribed as part of the patient’s
treatment for rheumatoid arthritis
with directions to be taken once a
week on the same day.
“The setting out of the patient’s
medication into a DAA was carried
out by a pharmacy technician,
who incorrectly packed the
methotrexate to be taken every
day.
“This incorrect packing was done
for two separate weekly packs.”
The packs were checked by two
pharmacists on consecutive weeks,
both releasing them for patient use.
The patient developed mouth
ulceration and was admitted to
hospital, where the error was
picked up by hospital staff.
The patient died some days
later in hospital and the case was
referred to the Coroner’s Office,
who found the cause of death
was immune system compromise
caused by the toxic effects of
methotrexate dispensed and
incorrectly packed as daily instead
of once weekly.
“The Committee found that
the pharmacists’ professional
performance was unsatisfactory,
and referred the matters for
hearing by a Professional
Performance Standards Panel.
“This case underscores the
Board’s concern when pharmacists
dispense and subsequently pack
into a DAA for later consumption by
the patient, of drugs with a narrow
therapeutic index.
“Extra vigilance is required to
be exercised by pharmacists with
these drugs.”
For more, CLICK HERE.
The above article was sent to subscribers in Pharmacy Daily's issue from 16 Jun 14To see the full newsletter, see the embedded issue below or CLICK HERE to download Pharmacy Daily from 16 Jun 14