Media Release: Heart patient falls asleep at wheel on busy highway after chemist wrongly dispenses sleeping tablets

Media Release from Queensland Consumer Watch
- Call for State Government crackdown on chemists after near accident on Ipswich Motorway when heart patient wrongly given sleeping tablets -


A state government investigation is underway into an incident on the Ipswich Motorway when a driver fell asleep at the wheel of his car after mistakenly being given sleeping tablets instead of heart tablets by his local chemist.

The Redbank man had been wrongly taking the sleeping tablets for 5 days before the mistake was discovered.

He pulled over at the Goodna exit during the peak hour rush after nodding off on the 100,000 vehicles a day motorway.

The driver later confronted the chemist and has lodged an official complaint with the Pharmacists Board which is investigating the incident.

Queensland Consumer Watch spokesman Paul Tully has called for a crackdown on chemists dispensing wrong prescriptions.

He said the case highlighted the need for chemists to take more care in dealing with the public.

"The average consumer wouldn't know the fancy names being used by pharmaceutical companies and could easily be confused if given the wrong medication.

"This incident could have resulted in a major tragedy on the Ipswich Motorway as a direct result of professional incompetence.

"Pharmacists are university trained professionals who should never get this sort of thing wrong.

"The State Government must act firmly over this potentially-deadly incident to ensure it never happens again," Paul Tully said.

............................................
ORIGINAL EMAIL COMPLAINT:

(Personal details have been omitted by Queensland Consumer Watch.)

Copy of this email addressed to and faxed to:

Pharmacists Board of Queensland at Office of Health Practitioner Registration Board 

To whom it may concern. 

Last week I presented at my local Chemist, (name deleted), and requested Minax (Metoporol) tablets via a script supplied by Dr (name deleted).

I have been taking Minax, one tab twice a day for heart condition. The script was processed by (name deleted), the Chemist owner of the Pharmacy and on my arrival home I removed the bottle from the pharmacy packet and noticed that it was different to normal Minax.

The bottle was the same white plastic with a blue safety-lock lid and the label attached by the Chemist indicated "Metoporol" with Minax shown under but in smaller print and with the instructions to take one tablet twice a day. 

The difference that I noted was that instead of the usual bland Minax original label on the bottle, the original label on this bottle was a bright purple/red label showing 'PROZAM or PRAZAM'.

It was quite noticeable and fortunately not covered over by the Chemists add-on label described above.

I noticed the different label but thought it must have been a generic brand of Minax.  (My usual Avapro blood pressure tables have recently been supplied as Karvea, a generic alternative) and not knowing otherwise I believed that the Prozam was a generic brand of  Minax/Metoporol. And as stated,the Chemists label indicated Metoporol/minax.

I have no qualms about using or being supplied with a generic alternative. 

On the weekend I commenced to use the new bottle as the previous bottle had run out. 

I noted that the tablets in the new bottle were red/orange in colour and I again assumed they were a generic substitute and continued to take one tab morning and night. 

I did not get alarmed for the first few days but felt lethargic and as soon as I relaxed, tried to read the paper or watch TV, my eyes became heavy and I had a feeling of tiredness and nodding off. 

I went to work, Redbank to St. Lucia Mon & Tues and felt very tired and weary, especially driving home and not responding easily to my early morning alarm wake up.

On Wed. I went by train to Wickham Terrace for a periodical ENT Specialist checkup. 

I could barely stay awake on the train both ways and whilst at the Drs waiting room I kept nodding off.  

Throughout that day I felt slightly squeamish in the stomach, but only slight and it did not concern me. 

That Wed. night I fell asleep whilst watching TV, something I have never done before.  I gave thought to the way I had been feeling and believed that I may have been getting a flu/virus or whatever. 

On Thurs 6.8.09 morning I fell asleep again after the alarm and was a good hour late for work and now cannot recall my drive to work. 

Again, lethargic all day and may as well have not been at work.  By the time I got onto the Ipswich Motorway on the drive home I felt very tired and should not have driven and at present with the new work there is nowhere to stop safely.  I turned off into the Goodna egress lane and stopped and walked around the vehicle and pondered my state of well-being.

I decided to check with the Chemist if the 'generic' tablets could be the cause, if not I would see my GP as to whether I had a flue/virus/whatever. 

I got to the Chemist and spoke to (name deleted) and then retrieved the bottle which she identified as sleeping tablets and not Minax. 

She was most apologetic and stated that she did not know how she made such a mistake ALTHOUGH there is a PROMINENT difference in the original labels of Minax and Prozam/Prazam. 

I am now aghast  at the mistake and implications, especially as I had been driving. 

Luckily I deduced that I was not my normal self and sought advice.  Other people or older people could have kept using the tablets until the bottle was empty or an accident/incident occurred. 

I will now not leave a Chemist until I have thoroughly checked or queried every item. 

One puts considerable trust in professionals such as Chemists.  

I now hope that the relevant Authorities could take action to have original labels altered to show what the tablet/medicine is for in simple layman terms.   MINAX with "For heart condition" or "heart treatment" shown under MINAX  and   PROZAM   with "Sleeping tablet" or "Sedative tablet" under or next to PROZAM and etc right across the broad range of drugs/medicines/tablets. 

Not knowing where to start, I have forwarded this information to the various addresses in the hope that the recipients can help towards amending or clarifying such anomalies that could be disastrous and to ensure that Chemists take better care. 

I do not believe that proper care was taken by the Chemist when my script was dispensed. 

If necessary this letter could be shortened to:  Patient believed sleeping tablets dispensed  and labelled by a Chemist for heart condition treatment, to be a generic brand in lieu of the normal heart treatment tablet, until uncharacteristic tiredness  caused the patient to ask questions. 

A simple addition to the label  showing what the medicine is for in simple terms would reduce mistaken use. 

(Name deleted)
Redbank

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PAUL TULLY: paul@tully.org.au

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