The fentanyl patch contained six times the prescribed dose and made the woman violently ill. Photo: BSIP via AFP
A woman overdosed after she was given six times the prescribed dose of a fentanyl patch by her pharmacy.
The Pharmacy Council is investigating the incident and the pharmacy involved says the "mistake" was the result of "human error".
RNZ earlier revealed Bellamere Arwyn Duncan died on 19 July after the two-month-old was given more than 13 times the prescribed dose of phosphate by a pharmacy.
A provisional post mortem report said she died from phosphate toxicity.
The revelations prompted the Ministry of Health and Health New Zealand to "urgently" undertake a joint review into the incident with MedSafe visiting the pharmacy to ensure it was safe to continue operating.
The Pharmacy Council, which is also investigating, said it was "clear that an awful error has occurred".
A Dunedin woman, who asked to not be named, visited her pharmacy on 24 July to collect her prescription of Fentanyl Sandoz.
She was told they did not have any available and was told to come back the following day. She said the pharmacist told her the product had changed.
Do you know more? Email sam.sherwood@rnz.co.nz
On 26 July she returned to the pharmacy and collected her prescription. She was prescribed patches which delivered 12 micrograms an hour and 0.3 milligrams a day.
However, she was unknowingly given patches which released 75 micrograms an hour, and 1.8 milligrams a day.
She put her first patch on about 8pm that evening.
In her complaint to the Pharmacy Council the woman said she began feeling nauseous about two hours later, and thought it could be related to the change in the patch she had been advised of but left it on as she was told it was okay.
"By 1am I was violently ill, vomiting and lying on the bathroom floor trying not to wake up my children and partner.
"I couldn't open the fridge to get water or fluids as my hands didn't work. I fell over multiple times."
She eventually ripped the patch off because she was so unwell.
The following evening her partner looked at both her new medication and her old one and they then realised she had been given six times her recommended dose.
She emailed the pharmacy and informed them what had happened as she did not want it to happen to anyone else.
She said the pharmacy called her the following morning and was "very concerned and apologetic" and sent her gifts and offered to pay her for her time off work.
The woman said she was still recovering from what happened weeks later.
One of the owners of the pharmacy told RNZ the matter was with the Pharmacy Council.
He said what happened was a "mistake" that was the result of "human error".
He said the incident was "very concerning", and was unable to comment further until the investigations had been completed.
A Pharmacy Council spokesperson confirmed they had received a notification and were "proceeding with an enquiry".
A Ministry of Health spokesperson said they had been made aware of the complaint and would be "working closely" with the Pharmacy Council to gather more information.
Associate Minister of Health Matt Doocey said Medsafe had informed him they were working closely with the Pharmacy Council to look into the incident.
"It would be inappropriate to comment while this process is under way."
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