Lanny Wong: director of Mangawhai Pharmacy voices support for law changes after death of two-month-old

There's calls for law changes among experts after a 2-month-old baby died after she was allegedly given medication at an adult dosage by a pharmacy.

This incident has prompted the Ministry of Health and Health New Zealand to 'urgently' undertake a joint review into the incident.

Lanny Wong, director of Mangawhai Pharmacy and a member of the national executive of the Pharmaceutical Society says something's clearly gone wrong - and an investigation is needed.

"It does seem out of place, I don't think any pharmacist would disagree with your sentiment. Obviously, something went wrong here and we need to understand what that is."

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Episode Transcript

Speaker 1 (00:00):
There are calls for tougher rules for pharmacists after the
death of a two month old baby who was wrongly
given an adult dosage of medicine. Now the child's parents
and also a NICU doctor are questioning why pharmacists don't
have to have their medication checked by a second pharmacist
before they dispense them to a client. Lanny Wong is
the director of mung of Phi Pharmacy and sits on
the National Executive at the Pharmaceutical Society. Lanny, Hello, Gerda Heather.

(00:25):
Do you think that every medication should be checked by
a second set of eyes or just medication for kids?

Speaker 2 (00:32):
You know, in the perfect will? Yes, double checking is
a good idea, yep, for all of them, for everything. Yes,
I would agree with that. Yeah, and that is that
is actually what is recommend It is to double check.
Even if you're by yourself, you're meant to double check
your own work.

Speaker 1 (00:50):
Does that happen?

Speaker 2 (00:53):
Yes? And though you know most of most of the time,
farmists do their best, but often the system doesn't allow
us to do that.

Speaker 1 (01:00):
Why not too busy?

Speaker 2 (01:02):
Yeah, Well, it's a very complex thing to explain, but
the easiest way to sort of explain this is that
we have a system that prioritized volume over value. So
there's a fundamental flaw and the way our funding model
is shaped, so as you know, the way pharmacy revenue
comes is tied to the quantity of item with the spend.

(01:22):
You know, So, for example, if you come across a
complex prescription that requires a lot of clinical thinking, a
lot of sorting out, a lot of contacting prescriber to
discuss clinical reasoning, all that takes time and it can
take up to a few hours. So when you have
a situation like that, you know, you could be spending
that time, you know, sorting out all the backlog of

(01:44):
prescription and you'll be remunerated for sorting out the back lock,
but you won't be remunerated for sorting out a very
complex description.

Speaker 1 (01:52):
Well, everybody, everybody's remunerated for being productive, aren't we forgetting
as much done as possible as fast as possible?

Speaker 2 (01:58):
Yeah, that you put it, You put it quite here
this so we're being remuneratedble being productive.

Speaker 1 (02:03):
Yeah. Now this thing that the kid was given, so
was this baby girl was premature? She was given phosphate?
What is just out of interest? What does phosphate do
for a prem baby.

Speaker 2 (02:15):
Yeah, so you look, I'm not as specialist. I think
the neco specialists that explained that in his article, like
young babies, they tend to have pre sort of premature
absorption system, so they do have lack of certain type
of you know, virol and mineral. So phosphate is one of.

Speaker 1 (02:34):
Those, right, Okay, so it's giving them something that they
don't have.

Speaker 2 (02:37):
Okay, that's correct. Now.

Speaker 1 (02:38):
I would have, Lenny, I would have thought that, you know,
I mean, you can take a punt with me. I'm
in my forties. Who cares, you know what I mean?
But I would have I would have thought that if
a farmister's pharmacist is dispensing something for a two month
old baby, you would double triple, quadruple check it. Would
you not have thought?

Speaker 2 (02:55):
Yeah? I would, Yeah, I would. There will be the
normal assumption. However, you know, like in terms of what
happened here is it's really hard. That's why pharmacists support
a full and transparent investigation to find out what happened.
It does seem out of place. I don't think any
pharmacists will disagree with your sentiment. You know, obviously something

(03:16):
went wrong here, and we need to understand what that is.
Because the work we do a contact scripts like that,
you know, a lot of you know, we call it
the Swiss cheese model. A lot of things can go wrong. Yes,
you know, when something's missed and you know, we don't
know the nature of this description.

Speaker 1 (03:33):
It could be Do you not think I mean, do
you not think I acknowledge that you guys are just humans? Right,
You're not robots, You're humans. You're gonna you're gonna have
a fight with your child in the morning, and you're
going to be you're gonna be annoyed when you come
to work, or you're going to be tired, or maybe
you had one too many beers last night or whatever.
So actually, considering all of that, should we not, as
people receiving the medication double triple check at ourselves, given

(03:54):
that we've got access to chat GPT, now, should we
not be pumping that in and going is this a
standard dose for a woman of forty?

Speaker 2 (04:02):
Yeah? I think you know, yes, yeah, you know that
that is certainly in option. But you know, most of
the time people that come and then pick up description,
they are not well, so they're not thinking clearly. Most
of the time, and they are probably in the very
vulnerable position. Yeah, and I think you know, for young parents,
you know, they're obviously very sleep deprived. You probably understand
that yourself, so they're probably not thinking clearly, and you

(04:24):
know a lot of things can you know, affect that.
And I think you know this is this is one
of those things. That's why you know, health professional advice
is important.

Speaker 1 (04:33):
Yeah, okay, Lenny, I appreciate your time. Thanks so much,
Lenny Wong Mung of PHI Pharmacy. Also, as I said earlier,
SIT's on the National executive at the Pharmaceutical Society. For
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