Editor, – Ms McCullagh (Aust Prescr 2005;28:5-7) raises an important point and one that has been brought to the attention of the Pharmacists Board of Queensland. The Board recently undertook disciplinary action against a pharmacist who dispensed a prescription for methotrexate where no label was placed on the bottle holding the tablets. As a direct consequence of the lack of a label, the patient took the wrong dose of methotrexate and was admitted to hospital a few days later with severe toxic manifestations.
The Board subsequently received credible information indicating that the practice of labelling only the exterior packaging when dispensing methotrexate was a not infrequent occurrence. Subsequently it wrote to all Queensland pharmacists highlighting the inherent risks associated with such practice.
The Board supports the comments made by Ms Deans, of the Pharmaceutical Society of Australia. However, it would emphasise that there are very few instances where a pharmacy dispensing label is not able to be securely attached to the container holding the medicine and certainly none where a drug with a narrow therapeutic index is involved, where any patient confusion as to the dose may have dire consequences.
Peter Brand
Chairperson
Pharmacists Board of Queensland
Brisbane
