A Complaint Involving the Dispensing of Methadone 1mg/ml Oral Solution

The Professional Conduct Committee (PCC) heard a complaint in which the incorrect amount of Methadone was supplied to a patient for five consecutive days.

The patient presented two prescriptions for Methadone 1mg/ml oral solution. The first prescription was for supervised consumption of 30mls per day, for three days, total quantity 90mls. The subsequent prescription was for supervised consumption of 40mls per day, for three days, total quantity 120mls. This was the first time that the patient had been prescribed methadone and the first time that they had attended at the pharmacy.
The pharmacist gave evidence that she was not aware that the patient was just starting on methadone and that he was on an initial dose that would be increasing.
The pharmacist misread the prescription and dispensed 90mls for the patient for supervised consumption.
The next day another member of staff printed the label for methadone for this patient from the Patient Medication Record on the computer.
The pharmacist gave evidence that on the pre-printed label she saw 90mls, looked at the prescription but didn't read it properly, so again supplied 90mls to the patient.
The pharmacist presumed that it was a seven day prescription and continued to dispense 90mls to the patient for the next three days (5 days in total).
As soon as the pharmacist realised the mistake she contacted the patient’s doctor to inform them.

Important Learnings

Learnings from this complaint should be shared with all staff members. You should review your pharmacy’s policies and procedures which relate to the methadone treatment service, as well as your own practice, to help ensure a similar incident does not happen in your pharmacy.

This complaint highlights the following important learning points:

There should be written policies and procedures in the pharmacy for all aspects of the methadone treatment service. Following clear procedures ensures consistent performance of a task to the required level and ensures that the system is as robust as possible.
A procedure should be in place for patient’s that are initiating treatment with methadone and/or receiving methadone from your pharmacy for the first time. This should include details of what documentation to check to ensure that the correct patient has presented at the correct pharmacy, information for the patient with regard to how the service works, relevant contact details, and counselling on the proper use and storage of methadone, as well as any other relevant information specific to your pharmacy, for example the opening times of the pharmacy, any days that the pharmacy is closed etc.
It is important that all relevant staff members, and any locum pharmacists that will be providing this service, are trained on and following the pharmacy’s procedures so that patients are provided with a safe and consistent service. If you are new to a pharmacy or work as a locum pharmacist you have a responsibility to ask for, and familiarise yourself with, the procedures of the pharmacy.
All patients receiving methadone for opioid dependence must be registered on the Central Treatment List and assigned to a specific pharmacy. Where a new patient has been assigned to your pharmacy, all relevant staff members should be made aware of when the patient is expected to start treatment.
When you are not familiar with a patient you must always confirm the patient’s identity before dispensing methadone to them by requesting photographic ID and/or referring to their treatment card which should be easily accessible in the pharmacy.
Daily dosing is a potential area for complacency, when dispensing an instalment from a methadone prescription you must always check the dose against the original prescription. Dispensing methadone from a dispensing label or the Patient Medication Record (PMR) often compounds an error made on the first dispensing. At any time a patient’s dose may change, therefore you must confirm the dose at each dispensing and not assume that you know their dose.
Methadone is a very high risk medicine and has well known toxicities that are dose dependent, and can be fatal. You have a responsibility to ensure that this medicine is dispensed and supplied safely, therefore extra vigilance is needed when dispensing this medicine. Where at all possible this should include an accuracy check by a second member of staff to confirm that the dispensing label and quantity dispensed matches the quantity prescribed.
The pharmacist should also verbally confirm the methadone dose with the patient before supplying it to them, this provides a final check of the dose and helps the patient to be informed about their treatment.
An error log should be completed for all errors made in the pharmacy, and the staff members involved should be informed of the error. Recording errors should not be used as a way to blame individuals, but rather to encourage an environment of openness and learning, so that procedures can be reviewed and amended, and practices changed to guard against similar errors happening again.
The PSI has produced Guidance for Pharmacists on the Safe Supply of Methadone (Undergoing update to reflect 1 March 2024 legislative amendments) and Inspectors' Advice on Balance Checks and Reconciliation in relation to Methadone Products which may also help you to review your practice.