It is no surprise that the top four drugs on our list are Schedule 8’s (S8s). Dispensing errors can happen with any drug but the top four are also prone to diversion, forgeries and theft. Another reason this group is overrepresented is that some of them are available in immediate release (IR) and sustained release (SR) presentations.
The top 10 are as follows:
1. Oxycodone
Incident reports for this drug are connected to forgeries and scams where illicit use and diversion are involved.
Oxycodone is also the subject of regulatory enquiries, especially if supply by a pharmacy is excessive and beyond therapeutic guidelines. Careful reference to and observance of repeat intervals, reference to Real Time Prescription Monitoring and ensuring prescriptions meet all legislative requirements will minimise your chance of being the subject of an investigation.
Another error observed is where a pharmacist supplies a larger quantity than the prescription authorises. Oxycodone IR (usually Endone) is often prescribed at 10 tablets but the original pack of 20 is provided. Staged Supply orders can also be overlooked resulting in a high-risk patient being supplied the full quantity.
2. Tapentadol/tramadol
Tapentadol and tramadol are often confused so the two drugs can be switched in error either way. The common brand of Palexia comes in both an IR and an SR version, so an error can occur where the wrong release mechanism is provided. Tramadol also comes in a 50mg format which is available in IR and SR formulations.
3. Methadone
Methadone does feature in reports to PDL as it is involved in overdosing.
These overdoses are generally caused by the pharmacist mixing the dose in mg and mL because methadone solutions are 5mg/mL so this can result in a 5x overdose. Other overdoses occur when the pharmacist provides a dose to the wrong client, usually the result of not checking the client photo or rushing the dispensing process.
Methadone is also involved in regulatory actions due to poor processes in the pharmacy. This can involve failing to keep the required records accurately, failing to keep cancelled prescriptions separate from other S8 prescriptions and incorrect storage of the solution.
4. Methylphenidate
Methylphenidate (particularly Ritalin) is a top 10 contender due to the various presentations and brands that are available. Ritalin is another drug available in IR and SR formulations and it is sometimes confused with Concerta.
Some Australian states also have special prescribing wording that must be checked by the pharmacist for the prescription to be valid. As this drug is a psychostimulant, it can usually only be prescribed by psychiatrists and paediatricians. In NSW, this is indicated on the prescription by the addition of CNS and S28C numbers or a patient-specific AU reference number. Without this endorsement, the prescription cannot be dispensed.
Likewise, Queensland has the requirement that ‘Specified condition’, or words to indicate the condition being treated, must be annotated on the prescription.
5. Prednisolone
This drug comes in three widely separated strengths so dispensing errors can have significant implications (overdose or underdose). Prednisolone is also widely used to treat a variety of conditions in both adults right down to infants, so this is another reason it is involved in incidents.
Serious errors have occurred where prednisolone is packed in a DAA for patients in the community as well as aged care settings. If the ‘end date’ for supply of a high dose, short course of prednisolone is not recorded correctly, this can lead to the long-term provision of this potent medication with resultant adverse side effects. Likewise, the packing of a weaker than required strength of prednisolone can lead to treatment failure which can also impact the health of the patient.
Prednisolone also comes in a liquid presentation with a concentration of 5 mg/mL so the reader will immediately see the potential for error where the pharmacist confuses the dose in mg and mL.
6. Drospirenone/ethinylestradiol (Yaz 3mg/20mcg and Yasmin 3mg/30mcg)
As the active ingredients are the same, the strengths are very similar and the brand names are alike, it is obvious why these two combinations are involved in error reports. As the two formulations are very similar, the clinical impact may be minimal, but any dispensing error has the potential to escalate to an official complaint. Several errors with these two products have occurred when dispensed from an e-prescription.
7. Sertraline
As there are only two strengths available, there does not appear to be a logical reason why sertraline is involved in a number of error reports to PDL. Perhaps the high volume of prescriptions and the multitude of brands available could be a contributing factor. Providing the higher strength in error, especially for teenagers, can have significant clinical impact.
8. Semaglutide
This injectable drug is relatively new to the market so many pharmacists are encountering it for the first time. The tricky thing about Ozempic is that it comes in two presentations, both expressed with the same concentration of 1.34 mg/mL. Although the concentration of both forms is identical, the dose delivered by the pen devices is different which gives a high dose and a lower dose on delivery.
The low dose form of 1.5 mL is used to initiate treatment of type 2 diabetes (and weight loss as off-label use) to limit nausea which is encountered when first using the drug. If the high dose form of the 3 mL pen is provided in error on treatment initiation, this will clearly result in extreme nausea when used by the patient.
There have been complaints made where pharmacists have refused to provide Ozempic for weight loss as they have not realized it can be provided for this indication as off-label prescribing (*see footnote added below on 11 August 2022).
9. Atropine eye drops
Despite previous Practice Alerts warning of the danger of not recognising prescriptions for atropine 0.01% eye drops, this issue continues to be reported in dispensing errors. Some pharmacists are unaware of this weaker strength’s existence and assume that atropine 1% (Atropt) is being prescribed. Naturally, the provision of the higher strength, usually to a child, will elicit extreme pupil dilation and associated discomfort and blurred vision. Any incident involving a child has a higher chance of being reported to a regulator than when an adult is involved. PDL has previously assisted pharmacists who have been the subject of a notification for making this dispensing error.
Atropine eye drops 0.01% no longer need to be compounded as a proprietary line called Eikance is now available.
10. Special mention: carbAmazEPINe and carbImazOLe
Alarm bells should ring whenever you see one of these drugs prescribed as they can be confused and interchanged by pharmacists and dispensary technicians.
When manually looking for a drug in a menu, a common shortcut to typing the full drug name is to use the first four letters. Doing this will bring up both drugs so selection errors do occur when this shortcut is used. Also, these generic names do look and sound similar which also leads to errors.
Choosing the wrong drug to the one prescribed can have serious side effects for both these molecules. If carbamazepine is not provided when prescribed, the patient can suffer a loss of seizure control. If carbamazepine is prescribed for mood stabilization, a patient given carbimazole in error can experience severe behavioural changes.
Providing carbimazole to a patient expecting carbamazepine can cause serious endocrine problems as these patients can suffer hypothyroidism.
Errors in providing these two drugs often goes undetected for a long time due to the large quantity of tablets that are provided on the prescription.
Immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7, Australia-wide.
*PDL update regarding supply of semaglutide (Ozempic)
PDL would like to provide further advice regarding the supply issues for semaglutide (Ozempic).
Novo Nordisk has advised the Therapeutic Goods Administration (TGA) that the intermittent availability of Ozempic will continue until the end of December 2022. As such, prioritising Ozempic supply to people with type 2 diabetes is recommended to ensure continuity of care during the shortage. See the joint statement released by the TGA on 4 August 2022. While semaglutide may be prescribed off-label and outside of Ozempic’s approved indication, pharmacists need to use their discretion when handling requests for supply.
Any action to limit supply is not always well-received by patients, and PDL is aware of complaints being made where pharmacists refused to provide Ozempic for weight loss when presented on a valid prescription. This may be more likely when the TGA recommendations and the pharmacist’s responsibilities have not been well communicated to a patient. The risk of dissatisfaction or complaint does not negate the need for pharmacists, wherever possible, to continue prioritising the supply of Ozempic for people with type 2 diabetes.
We would encourage PDL members to remain abreast of the current supply situation and work together with patients so that timely supply can be organised. If you receive a complaint about your practice, please contact the PDL Professional Officers on 1300 854 838 for further support and advice.
