Purpose

This paper provides a brief report on the incident of dispensing wrongly-mixed cough medicine at Central Kowloon Health Centre and the follow-up actions taken by the Department of Health (DH).

Background

2. The concentrated form of the cough medicine is manufactured centrally and distributed to the clinic dispensaries in bulk. This medicine is then diluted and bottled for dispensing to individual patients. For bottles of 500 ml and one litre capacity intended for use over two to six weeks, Chloroform water would be used for dilution instead of water for its preservative effect. It is prepared by mixing large proportion of water with spirit chloroform, which is a solution of pure chloroform in alcohol. If pure chloroform were used, instead of spirit chloroform, the chloroform would sink to the bottom and be clearly visible after mixing with the cough medicine as chloroform is not very soluble in water.

The Incident

3. On 9 March 1998, two bottles of a cough medicine (Expectorant Stimulant) of 500 ml and one litre capacity were found to contain a small but visible amount of chloroform at the bottom of the bottle.

4. Upon investigation, it was found that a qualified dispenser employed on a temporary basis had used undiluted chloroform instead of spirit chloroform during the process of preparing the medicine. This error had occurred on three occasions and a total of 36 patients had been issued with the wrongly-mixed cough medicine.

5. In the present incident, the chloroform taken from a well shaken bottle would not give rise to toxic effect. It is not expected that toxic effect would occur unless the chloroform collected at the bottom of the bottles is taken.

Follow-up Actions

6. Immediately after the discovery of the incident, the DH has taken the necessary follow-up actions promptly, including initiating the investigation into the incident, contacting the patients who had been given the wrongly-mixed cough medicine and informing the public of the incident.

7. By reference to the pre-packing record, the computer record of drugs dispensed, the medical record of patients and the batch number labelled on the bottles, the staff of the DH, beginning from 10 March 1998, started to contact the 36 patients who had been given the cough medicine in question. They have been able to reach all of them, except one, who has not provided a contact address to the Department.

8. Among the 35 patients contacted, 30 had visited the Health Centre for exchange of the medicine and medical advice. Among the 30 patients who had returned the medicine, 17 had taken the medicine. Eight of them reported transient and mild discomfort after taking the medicine.

9. The DH held a press conference on 12 March to inform the public of the incident.

Improvement Measures to the Dispensary Service

10. Since January this year, a task force headed by a Deputy Director of the DH has started to examine the Department's dispensary procedures and has noted some inconsistencies in practice from clinic to clinic. A manual of good dispensary practice has been prepared and is now being circulated among staff for comment. We expect the final version to be issued within April 1998.

11. A review of the staffing situation in the DH's dispensary service, including manning scale and the grade/rank of staff to be deployed, is being conducted and will be completed by July-August 1998.

12. Separately, as an immediate measure, more staff have been deployed to the Department's pharmaceutical manufactory to pre-pack large bottles of the cough medicine for use by clinics. This will minimize the need for dilution procedures in clinics. The Department is also exploring the possibility of purchasing some of the cough medicine available in the market.

13. Other measures being introduced include the strengthening of orientation programmes for temporary dispensary staff and new recruits, and enhancing the in-service training of dispensers.



Department of Health
March 1998