Frequent flyers

PA Frequent Flyers

There are certain medications that appear in notifications to PDL frequently. While some of these medications are considered low risk and have less potential for harm, it is important for pharmacists to remain vigilant when checking all prescriptions. Here are some examples of medications that have recently seen an increase in reports to PDL.

Ozempic injections

Ozempic™ is a non-insulin injectable used to treat Type 2 diabetes in adults 18 years and above.

Since semaglutide induces side effects on initiation, lower doses are required for at least the first four weeks of use. Side effects include nausea, vomiting, diarrhoea, and abdominal pain.

Dispensing errors are occurring as pharmacists are not aware that this new medication comes in two sizes delivering different amounts of the drug.

There is a 1.5 mL pre-filled pen that delivers 0.25 mg or 0.5 mg for initiation of the drug. The 1.5 mL pen is used to provide a starting dose of 0.25mg once a week for four weeks. The dose may then be increased to 0.5mg weekly using the 1.5 mL pen.

There is also a 3 mL pen that delivers 1mg of semaglutide which is used when a patient progresses to a higher dose. If BGLs remain elevated, the patient will then require the 3 mL pen to deliver a dose of 1 mg.

Confusion can arise as both size pens contain 1.34mg/mL of semaglutide but deliver different volumes to achieve the desired dose. Please check carefully.

Combination products

Combination products can cause confusion at times, and this has been exacerbated recently with the introduction of Active Ingredient Prescribing (AIP).

Combinations of statins and ezetimibe have featured frequently in recent reports. It seems some pharmacists may not be checking duplicates carefully, therefore these errors are often carried on for several months before the error is detected. Whilst there are rarely side effects or issues with this kind of error, it does cause confusion and concern for both patients and prescribers.

Other combinations that can be particularly problematic due to recent AIP changes include perindopril/amlodipine (Coveram™) and oxycodone/naloxone (Targin™).


Low-strength atropine eye drops are often prescribed by eye specialists or optometrists to correct myopia (near sightedness) in children and teenagers. These drops are not commercially available and must be prepared by a compounding pharmacy. The problem occurs when a consumer presents the prescription to their regular pharmacy and atropine 1% (Atropt™) is dispensed. The resultant extreme dilation of the pupil and sensitivity to light often results in an angry parent who may seek recompense for extra medical costs and possibly lost wages caused by caring for the affected child.

Please note, compounded Atropine eye drops must be prepared by a compounding pharmacy using a sterile facility. Under no circumstances are eyedrops to be prepared in non-sterile conditions.


We have received several notifications regarding vaccine incidents this year. Common complaints from patients include:

  • Receiving the incorrect vaccination – For example, booking for a whooping cough vaccine and receiving an influenza vaccine.
  • Receiving an expired vaccine which is administered by a pharmacist or prescriber. Meningococcal vaccines are often short dated.
  • Patients receiving the incorrect formulation for their age group including influenza vaccines and meningococcal vaccines.
  • Cases of shoulder injury related to vaccine administration (SIRVA).

Many of these incidents may be prevented by consistent and professional process. Members are reminded that checking the AIR prior to vaccination is good practice and a requirement in some states.

Please refer to our previous Practice Alert on vaccinations that was released in April.

Milligrams and Millilitres

Mixtures expressed in mg/mL are frequently implicated in dispensing errors reported to PDL.

Examples of mixtures that seem problematic include methadone 5mg /mL, various strengths of morphine liquid (Ordine™) and Prednisolone mixture 5 mg/mL (Redipred™, Predmix™).

It is common for these medicines to be prescribed in milligrams rather than millilitres. For example, a script for Predmix™ 15 mg is dispensed and labelled as 15 mL, equivalent to 75 mg, being directed to be given. This error often has clinical consequences as a child given a higher-than-expected dose of a cortisosteroid will be restless and will not sleep well. This in turn will distress the parents who will often escalate the matter, irrespective of the impact of the error, as it involves a child.

Some pharmacists provide the actual dose in brackets so the above scenario would read: Predmix 5 mg/mL. Give 3 mL (15 mg). Expressing the actual dose in mg would hopefully alert the dispensing pharmacist that the dose dispensed was too high.

For immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7, Australia-wide.