The Medical Association will review drug dispensing guidelines sent to 6,500 general practitioners last year after a similar blunder killed four patients.
But pharmacists said the latest incident proved that guidelines were not effective enough. A separation of prescribing and dispensing was the only way out in the long term, they said.
A month after 153 people with stomach ailments were found to have been given the diabetes drug gliclazide by Wong Tai Sin doctor Ronald Li Sai-lai in May last year, the association formed a taskforce on drug dispensing.
The taskforce released the Good Dispensing Practice Manual in July last year, urging doctors to follow a system of 'three checks and seven rights' at all times to prevent prescription blunders.
'It's time to review the guidelines,' taskforce co-chairman Cheng Chi-man said. 'It's been a year already [since the diabetes drug blunder]. Some doctors may have relaxed their vigilance.'
He said questionnaires might be sent out later this year to all taskforce members to collect their opinions and practice patterns.
The three 'checks' are checking the container label before taking it off the shelf, checking it against the prescription and checking it before putting the container away. The seven 'rights' are checking for the right date, patient, drug, dose, route, frequency and container.
Dr Cheng admitted that it was such a complicated procedure that some minor mistakes might occur.
He and association chairman Choi Kin said investigations were needed to confirm whether the latest blunder was made by the doctor or the drug company.
Dr Choi said that if the prescribing doctor, Hin Lin-yee, had done anything wrong, he could face disciplinary action, including a licence suspension.
Society of Hospital Pharmacists education director William Chui Chun-ming said the latest blunder showed that the guidelines were still not enough.
'In the short term, doctors should strengthen training of dispensing staff in their clinics. But in the long term, dispensing should be handled by professional pharmacists only,' he said.