Case studies learnings

These case studies have been published by the Pharmacy Board of Australia to help practitioners understand and meet their professional and legal obligations as a registered pharmacist.

Additional case studies can be found in past newsletter issues published by the Board.

The allegation

Owing to a dispensing error resulting in incorrect labelling of a dose administration aid (DAA), it was alleged that adequate procedures may not be in place at the pharmacy to manage public risk and a notification was raised in relation to the proprietors of the pharmacy.

The issues

During the investigation into the dispensing error that was the subject of a complaint to the Board, it was unclear who was responsible for the error, who undertook the final check of the DAA and who supplied it to the patient.

The lack of documentation and appropriate records raised concerns about the DAA service and whether the appropriate procedures were in place at the community pharmacy. As a result, a notification was raised by the Board in relation to the proprietors of the pharmacy to investigate whether the supply of DAAs at the pharmacy did not comply with relevant practice standards and Board guidelines.

The outcome

The Board received further information from the proprietor outlining the procedures relating to DAA’s that have been put in place since the notification. Having considered the information, the Board was satisfied that DAA procedures had been improved since the original notification and so no further regulatory action was required.

Lessons to be learnt

Pharmacists are expected to comply with relevant legislation as well as the profession’s standards and guidelines (including any other standards and guidelines referred to in those documents). The Board’s Guidelines on dose administration aids and staged supply of dispensed medicines outlines that the Board has regard to established practice and quality assurance standards, including the DAA service standards and guidelines issued by the Pharmaceutical Society of Australia (PSA), and the Society of Hospital Pharmacists of Australia (SHPA).

The Board’s guidelines outline information that should be included in the record of each packing into a DAA in addition to meeting state and territory legislative requirements. This includes recording who packed and checked the DAA. The Professional Practice Standards published by the PSA articulate the expected standards of professional behaviour of pharmacists in Australia. Standard 15: Dose Administration Aid Service outlines criteria including policy and procedures and documentation. The standard states that the packing date and intended start and expiry dates should be clearly documented on the DAA label. Maintaining documentation that tracks which DAA’s have been packed and supplied by whom and when is also required.

The Board’s Guidelines for proprietor pharmacists outlines that a proprietor must maintain an active interest in how the pharmacy business is conducted to ensure that the pharmacy operation is in accordance with:

  • any applicable state, territory or Commonwealth law
  • relevant Pharmacy Board of Australia policies, codes and guidelines
  • applicable professional practice and quality assurance standards and guidelines, and
  • good pharmacy practice.

Proprietors are required to maintain awareness of the practice at the pharmacy and intervene as required to ensure the pharmacy business is conducted properly.

The allegation

It was alleged that a practitioner made false and misleading declarations about meeting the Board’s recency of practice requirements on their renewal of registration applications lodged annually over the previous three years.

The issues

Although the practitioner had practised as a pharmacist overseas, they had not practised as a pharmacist in Australia for several years but continued to declare that they met the Board’s recency of practice requirements. As outlined in the Board’s Registration Standard: Recency of practice, the Board considers that practise in Australia or New Zealand meets the requirements of the standard.

Had the practitioner truthfully declared that they did not meet the recency of practice requirements when renewing their registration, the Board’s Registration and Examinations Committee would have reviewed their application to determine what action the practitioner must undertake to renew their general registration and practise in Australia.

Knowingly making a false declaration is considered by the Board to be a serious professional conduct matter and may be dealt with by the Board through the disciplinary mechanisms available under the National Law1.

The outcome

The Board considered the practitioner making a false and misleading declaration to be unsatisfactory professional conduct and cautioned the practitioner with respect to falsely declaring that they had met the requirements of the Board’s Registration Standard: Recency of practice.

Lessons to be learnt

Pharmacists are required to maintain regular practice experience as part of the process of maintaining competence to practise and providing services to the public in Australia. To meet the recency of practice standard, pharmacists are required to have practised regularly (in Australia or New Zealand) and within the previous three years in their intended scope of practice.

If you are unable to demonstrate recency of practice (more than 450 hours within the previous three years or 150 hours in the previous 12 months in Australia or New Zealand in your intended scope of practice), or are changing your scope of practice, you will be required to demonstrate to the Board that you are competent to practise. In these circumstances, the applicant would have been asked to provide the following information:

  • when they last practised in Australia or New Zealand 
  • their intended and previous scope of practice as a pharmacist
  • a detailed practice history, and
  • activities carried out since they last practised as a pharmacist, including any continuing professional development.

The above information would enable the Board’s Registration and Examinations Committee to determine whether the applicant would need to complete a period of supervised practice, continuing professional development and/or examinations to ensure their competence to practise in Australia.

For more information, view the full registration standard online.


1The Health Practitioner Regulation National Law, as in force in each state and territory (the National Law).

The allegation

A notifier alleged that inappropriate comments published on a pharmacist’s personal Facebook page concerned the practitioner’s personal views on abortion. Although the Facebook page was a closed group, pharmacy patients were members of the group. The pharmacist’s Facebook page included photos of the practitioner at work as a pharmacist. The notifier was concerned that pharmacy patients may be subject to judgement in certain circumstances and may not receive unbiased or timely healthcare.

The issues

The allegation raised issues concerning the practitioner’s responsibilities when using social media as outlined in the Social media policy developed by the National Boards. When using social media, pharmacists should remember that the National Law, the Pharmacy Board’s Code of conduct for pharmacists, and the Guidelines for advertising regulated health services (the advertising guidelines) apply. Whether or not an online activity can be viewed by the public or is limited to a specific group of people, registered health practitioners need to maintain professional standards and be aware of the implications of their actions, as in all professional circumstances.

Registered health practitioners should only post information that is not in breach of these obligations by:

  • complying with professional obligations
  • complying with confidentiality and privacy obligations
  • presenting information in an unbiased, evidence-based context, and
  • not making unsubstantiated claims.

The Board’s Code of conduct states that good practice includes being aware that differences such as gender, sexuality, age, belief systems and other anti-discrimination grounds in relevant legislation may influence care needs and avoiding discrimination based on these differences. While individual practitioners have their own personal beliefs and values, there are certain professional values on which all practitioners are expected to base their practice. These professional values apply to the practitioner’s conduct regardless of the setting, including in person and electronically, e.g. social media, e-health etc.

The outcomes

The Board formed a reasonable belief that the practitioner displayed unprofessional conduct, with respect to inappropriate comments on social media and that the behaviour was below the standard reasonably expected of a pharmacist by the public or their professional peers.

When using social media, it is an individual's right to express their personal views. However, in this case, the Board considered the pharmacist’s use of social media to be in breach of the National Boards’ Social media policy and the Pharmacy Board's Code of conduct for pharmacists in that the practitioner:

  • failed to present information in an unbiased, evidence-based context
  • failed to demonstrate awareness of their own beliefs and how they may impact on the practitioner-patient relationship
  • failed to demonstrate awareness that differences in belief systems may inform the care needs of persons receiving healthcare, and
  • failed to demonstrate awareness of the cultural needs of patients, who might be privy to the Facebook posts, in the context of providing good health outcomes.

In this case, the Board formed a reasonable belief that the pharmacist’s conduct was unsatisfactory and proposed to caution the practitioner.

Lessons to be learnt

Pharmacists who use social media need to remember that their professional obligations continue when they are active online.

The Board’s Social media policy and Code of conduct for pharmacists both apply to all digital activity, including public forums and in closed groups.

The Social media policy provides guidance on pharmacists’ responsibilities and obligations when using and communicating on social media. Anyone using social media to advertise a regulated health service needs to meet the advertising requirements of the National Law. This includes removing any testimonials from a pharmacist’s social media page.

The Code of conduct for pharmacists sets out the required standards of professional behaviour, which apply to interactions in person and online.

Some of the principles that are useful to remember when active online include:

  • maintain professional standards and be aware of the implications of your actions, as in all professional circumstances
  • be aware of your ethical and regulatory responsibilities when you are interacting online – they are the same as when you interact in person
  • ensure that you protect the privacy and confidentiality of patient information, and
  • comply with the advertising provisions in the National Law and with the Board’s advertising guidelines.

The Social media policyCode of conduct for pharmacists and advertising guidelines are available on the Board’s website.

The allegation

A notifier alleged that a pharmacist failed to ensure patient privacy by affixing the pharmacy dispensing label to the primary container over the top of another label showing another patient’s details. The second label was easy to remove, and as a result the first patient’s details were accessible, resulting in a breach of confidentiality.

The issues

The allegation raised issues concerning privacy of patients as outlined in the Board’s Code of conduct for pharmacists and Guidelines for dispensing of medicines, which requires the practitioner to ensure the privacy of patients is assured and that the information about a person obtained through the course of professional practice is only disclosed with the patient's permission.

The initial dispensing label had not been removed from the medication when it had been labelled in error for an earlier patient. Because the medication had not left the pharmacy it was able to be reused. However, the initial dispensing label with the patient’s details should have been removed before dispensing the medicine to the next patient.

The outcome

The Board formed a reasonable belief that the pharmacist’s conduct was unsatisfactory and cautioned the practitioner.

Lessons to be learnt

Pharmacists must ensure that all pharmacy services are provided in a manner that respects and upholds a patient's privacy requirements in accordance with the Board’s codes and guidelines, as well as relevant privacy laws applicable to health providers.


The allegation

A notifer alleged that the practitioner allowed a pharmacy student to prepare and dispense a patient’s methadone dose without direct supervision and failed to check the dose before it was provided to the patient. As a result, the patient received a dose that was significantly higher than prescribed as the student had provided the dosage milligrams as millilitres.

The issues

The allegation raised issues concerning the roles and responsibilities of pharmacy staff. The Board’s Code of conduct for pharmacists outlines that good practice involves making the scope of the student’s role in patient or client care clear to the student, to patients or clients and to other members of the healthcare team. The code also states that the onus of supervision cannot be transferred and that any practitioner or student under supervision must receive adequate oversight.

The allegation also raised issues concerning proprietor responsibilities as outlined in the Board’s Guidelines for proprietor pharmacists, which includes maintaining an awareness of and responsibility for the services being provided, ensuring that the practice of pharmacy is conducted in accordance with applicable laws, standards and guidelines, that appropriate risk management procedures are in place for the operation of the pharmacy, and that business procedures, policies and protocols are routinely followed.

The outcomes

The practitioner demonstrated poor insight into his roles and responsibility as a supervising pharmacist. As a consequence, the Board considered it necessary to restrict the pharmacist from acting as a preceptor or supervisor of interns or students. In addition, the practitioner was required to undertake formal education and provide a reflective report demonstrating how the practitioner had incorporated the lessons learnt in this education into the practitioners practice as a pharmacist.

Lessons to be learnt

The dispensing of methadone for opioid replacement therapy (ORT) is an inherently high-risk area of pharmacy practice. The Board considered the supervision to be irresponsible, unprofessional and in the absence of safeguards (i.e. direct supervision) extremely dangerous.

Careful management of all aspects of supply of ORT is required by pharmacists in accordance with the jurisdictional legislative requirements including any policies and guidelines issued by local authorities. Pharmacists must also ensure compliance with pharmacy practice standards and codes and guidelines published by the Board.

The allegation

It was alleged that a practitioner dispensed a medication to the incorrect patient. When collecting the prescription, the patient was provided with a medication belonging to another patient with the same surname but different first name by a pharmacy assistant. As a result of this error the patient took a medication that was not prescribed for them and suffered adverse effects.

The issues

The allegation raised issues about patient counselling when supplying a medicine. The Board’s Guidelines for dispensing of medicines outline that patient counselling is part of the process of dispensing medicines and provides an opportunity to elicit the necessary information from a patient, and to provide the required information to enable safe and effective use of medicines. Counselling is also the final checking process to ensure the correct medicine is supplied to the correct patient.

The outcome

The practitioner's performance was considered to be unsatisfactory and the practitioner was cautioned.

Lessons to be learnt

The Board notes that there have been numerous similar cases like this in the last year. In this instance, the practitioner acknowledged the importance of checking that the first name and surname are correct at all times. Supply of medications to the incorrect patient can have significant health consequences. The pharmacist should make every effort to counsel, or to offer to counsel the patient whenever a medicine is supplied. Lack of counselling can be a significant contributor in failing to detect dispensing errors.

A notifier alleged that a patient was issued a repeat authorisation by a pharmacy for two additional supplies of a prescribed medicine without the authority or direction of the prescriber. For more information, please read the newsletter.

A notifier alleged that a pharmacist purchased OxyElite Pro capsules from a supplier in the United States and supplied the product to patients of the practitioner’s pharmacy. For more information, please read the newsletter.

A recent notification highlighted the importance of giving appropriate advice about medicines used during pregnancy or while breastfeeding. For more information, please read the newsletter.

Page reviewed 21/03/2019