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Wrong medicine Mum-to-be mistakenly given drug which could have caused abortion or foetal abnormalities, inquiry hears

Locum pharmacist, Donal O’Donovan, who admitted making the error with the prescription, was charged with three counts of poor professional performance over his error in dispensing a wrong and clinically inappropriate drug

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A pregnant woman (Yui Mok/PA)

A pregnant woman (Yui Mok/PA)

A pregnant woman (Yui Mok/PA)

A pregnant woman, who had suffered multiple miscarriages, was mistakenly given a drug by a Dublin pharmacy which could have caused her baby to abort or suffer foetal abnormalities.

An inquiry by the Pharmaceutical Society of Ireland heard the woman, known as Patient A, was dispensed the wrong medicine as a result of a locum pharmacist misreading a handwritten prescription from a hospital consultant.

Locum pharmacist, Donal O’Donovan, who admitted making the error with the prescription, was charged with three counts of poor professional performance over his error in dispensing a wrong and clinically inappropriate drug while working at Corrigan’s Pharmacy on Malahide Road, Clontarf on June 10, 2018 as well as failing to offer advice to the customer about her medication.

The PSI’s Professional Conduct Committee heard that Mr O’Donovan had given the woman a month’s supply of 200 microgram tablets of Cytotec – a treatment for gastric ulcers –when she should have been provided with 200 milligram tablets of Cyclogest – a drug used to increase the chances of a full-term pregnancy which is often prescribed to women who had suffered previous miscarriages.

Counsel for the PSI, Hugh McDowell BL, said Mr O’Donovan was accused of poor professional performance because he failed to meet the standard of competence expected of a registered pharmacist.

In a statement to the inquiry, Patient A, who was aged 34 at the time, said she had suffered multiple miscarriages including two in the nine months before being given the wrong medicine.

The woman said she had gone to Corrigan’s pharmacy on June 10, 2018 to get her prescription for Cyclogest as soon as possible after becoming pregnant again.

Patient A had hoped the pharmacist would talk to her as she had never taken the medication before but she had no interaction with Mr O’Donovan.

She recalled having taken two daily doses of the medicine before she and her husband noticed a “strange” warning on the packaging that it should not be taken by people operating heavy machinery when it was meant to be for pregnant women.

Patient A said she tried to vomit up the medicine once she realised she had been given the wrong drug which was harmful for pregnant women.

Once she confirmed what had happened with the pharmacy, the woman said she returned to the emergency department at the Rotunda Hospital.

Patient A notified the PSI about her concern as she felt she could have lost her baby if she had continued to take the wrong medicine.

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The inquiry heard Patient A suffered no ill effect and went on to have a healthy baby.

A PSI investigating officer, Shane McGlynn, said Cytotec was a drug that is not recommended for pregnant women or women of a child-bearing age.

Under cross-examination by counsel for Mr O’Donovan, Helen Callanan SC, Mr McGlynn said he had not asked anyone else to interpret the prescription written for Patient A by consultant obstetrician at the Rotunda Hospital, Karen Flood.

Ms Callanan noted that another staff member at Corrigan’s Pharmacy who was assisting her client on the day had also interpreted the handwritten prescription as being for Cytotec.

She pointed out that there had also been confusion over whether micrograms or milligrams was written for the dosage.

However, another pharmacist, Helena Buchanan, who appeared as an expert witness for the PSI, said the use of PV after the name of the drug on the prescription indicated it should be taken vaginally, while Cytotec is taken orally.

Ms Buchanan said questions should also have been asked why a consultant obstetrician and gynaecologist would be prescribing Cytotec and the fact that it was being given to a woman should have “raised a red flag”.

The witness said she believed that Mr O’Donovan should have realised he was dispensing “the wrong product", while his failure to speak to the customer represented another missed opportunity to detect his error.

Ms Callanan observed that the handwriting on the prescription was unclear, while the Irish Medication Safety Network had issued a safety alert in 2019 which warned that there had been confusion between the two drugs in Ireland and internationally.

In a statement to the PSI, Mr O’Donovan said he fully accepted responsibility for the error but claimed a misreading of a prescription was “not uncommon at some stage during a career in pharmacy.”

He said he had regarded a prescription for aspirin and Cytotec as a “logical clinical combination” which he had not questioned.

Mr O’Donovan with an address in Rathmines, Dublin who now works for a biotechnology company, said what happened had been “a huge wake-up call”.

The inquiry heard that after the incident Mr O’Donovan told his former employer that he no longer wanted to work as a community pharmacist.

Applying for the committee to deal with the inquiry by accepting a “genuine and heartfelt” undertaking by Mr O’Donovan about his future performance, Ms Callanan said her client was devastated by what had happened but asked for it to be recognised as “a once-off error.”

The PSI committee is expected to issue its ruling on Friday.

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