dispensing error report in press

[SolomonQ]

Morphine for baby in drug blunder (From The Argus)

ok, how can you mix a distinct pak such as oramorph with say any liquid pack never mind omeprazole liquid, either the pharmacist was highly incompetant or something fishy might have been going on e.g. "Remote Supervision"


also take a look at the daily mails take on this : http://www.dailymail.co.uk/news/arti...n-mistake.html

[kemzero]

Mistakes do happen and they can happen to you

So may external factors have been shown to be a contributing factor
but the following don't help

Pushy customers
Understaffed pharmacies
Poorly trained staff
One person being involved in the whole dispensing process e.g Pharmacist from start to finish.

Remote supervision will be every pharmacists worst nightmare , if POMs are allowed to be dispensed in our absence (e.g checking or sighting via videolink or other visuals, how can you be 100% certain , if screen is hazy or if you are concentrating on something else?

[the old merlin]

Yes..usual course of events I'm afraid. Lambeth will now cry "havoc" and let slip their legal pit-bulls in order to save face, and the girls will be hit again, this time by the people whose wages they pay. Class act isn't it? In recent stat-com cases, however, the presiding "judge" has recognised the possibility of a double-jeopardy case arising, and has dealt with it accordingly. The legal fees for the pharmacist are often crippling though, as it appears that they require to defend what essentially is the same case twice.

Not quite right in the "fine" case. I understand that the SAME lawyers represented both the employer and the pharmacist (and the technician), and it appeared that some sort of plea bargaining went on. This appears (I say appears because I'm relying on hearsay and the Press) to have meant that there was a "guilty" plea, and no discussion of the surrounding circumstances. It would also suggest that the employer paid the costs! No idea about the fine. Not even guessing, but IF the employer did, would suggest to me that higher management had some sort of "conscience" (I know, I know) about the reasons for the error.

Whether or not, when the Stat Comm will dig into that aspect obviously I don't know. One can only hope!
The Peppermint Water case wasn't reassuring on that, but maybe lessons have been learned!

[the old merlin]

Morphine for baby in drug blunder (From The Argus)

ok, how can you mix a distinct pak such as oramorph with say any liquid pack never mind omeprazole liquid, either the pharmacist was highly incompetant or something fishy might have been going on e.g. "Remote Supervision"

]

My thoughts exactly. I know Oramorph isn't legally a CD but it's very often treated as such.

[SolomonQ]

Mistakes do happen and they can happen to you

According to me Boehringer Ingelheim only have one oral solution pack with that colour scheme, (They only do two solutions-oramorph+Alupent) and their packaging is quite distinct, morphine sulphate liquid does not come in any other form. so how much negligence would it have taken for this mistake. All the excuses given in this case arent sufficient.

If the pharmacist gave out ramipril 10mg instead of ramipril 5mg, then maybe there would be some case, but not in this case in my opinion. One good example would be Teva's Prednisolone 5mg and Atenolol 50mg, both have exactly the same colour scheme.

[Asterix]

It's depressing me to know that we have to work for 5 years and then one possible mistake could lead to career damage/life damage.

The stupid papers never pick upon, arrogant and demanding customers, the fact that some technicians are crap at their job either.

[paul2008]

According to me Boehringer Ingelheim only have one oral solution pack with that colour scheme, (They only do two solutions-oramorph+Alupent) and their packaging is quite distinct, morphine sulphate liquid does not come in any other form. so how much negligence would it have taken for this mistake. All the excuses given in this case arent sufficient.

If the pharmacist gave out ramipril 10mg instead of ramipril 5mg, then maybe there would be some case, but not in this case in my opinion. One good example would be Teva's Prednisolone 5mg and Atenolol 50mg, both have exactly the same colour scheme.

Possibly the prescription was misread due to bad handwriting or whatever. A mistake on the level of mixing up lorazepam and lormetazapam. Having distinctive packaging does not make any difference if you misread the script or name: in fact it makes it worse which is why pharmacists read the label rather than recognise the pack and try to train their staff not to look for items on the shelf by looking for packaging but rather to read the product names.

[shan]

I agree with Paul. Most of the time the error is due to going by the colour sheme.

Another point is, before doing my OSPAP, in the pahrmacy I worked there used be lot of locums who checked by what is on the label and then confirming the product packing is same, overseeing what is actually in the prescription. This happens when you have more items on one script. And if you print labels by mistake the dispenser who picks product labels and not the script is bound to make a lot of mistakes.

Being a Pharmacist myself I dont know whom to blame? May be the work load, over confidence on the dispensing staff or self?

Atleast whenever I noticed this kind of an error, be it done by the Pharmacist or the dispenser, I always made it a point to tell them dont dispense by the label but dispense by the script and then re-check if the label is printed properly.

Another thing, in above cases it is not clear as to what was written on the script? Is there a chance the scripts were written wrong? In which case the Pharmacist should have done a proper clinical assessment before dispensing, I feel.

Having said this, it is too difficult comment on matters like this based on some news in papers than really knowing what had actually happened.

No-one makes any fuss or sue anyone for the WARS that killed thousands of innocent people, in the name of catching 1 person? What kind of world are we living in?

God save us Pharmacists from these news-mongers.

[SolomonQ]

Possibly the prescription was misread due to bad handwriting or whatever. A mistake on the level of mixing up lorazepam and lormetazapam. Having distinctive packaging does not make any difference if you misread the script or name: in fact it makes it worse which is why pharmacists read the label rather than recognise the pack and try to train their staff not to look for items on the shelf by looking for packaging but rather to read the product names.

As a locum, I find looking out for cetain brands etc.. is the easiest way to get to know where everything is in the dispensary, key meds include lipitor, persantin, etc... but abviously I do check while dispensing it is what I think it is.

I dont think that was the case, but if it was bad hand writing then dont you think the pharmacists should have made sure the doctor meant for the baby to have oramorph, I had a Rx for it a few weeks back and the directions said the dose in every 2 hours (normally it is every 4 hours), I went out and made sure with the patient's representative that, that was what the doctor meant, and the patient's situation fitted the prescribing pattern.

and all that for an adult, i'd be extra careful for a baby.