Dispensing error resulting in Jail Sentence

[Web Ferret]

My support goes to this pharmacist - This could happen to any of us. Shame on Tesco.

I'm not sure the RPSGB will/can do much given that this pharmacist has already resigned and considering their previous history of actually supporting pharmacists...

Well its good to see that the RPSGB have done something - they have issued a press release about decrimilising one off dispensing errors.

[kemzero]

My heart goes out to all parties concerned.

Every day without fail I always try to pray about the day ahead, that I spot mistakes before its too late .

What a precarious job we have....

Pharmacies should think twice before saying " It'll only be 5 mins or less, do you want to wait for it?" Our role has been trivialised for the sake of volume and profit which of course equates to greed. As long as employers ,the DOH etc continue to trivialise our role and chase profit margins Patient safety will continue to be compromised as to err is human especially when working conditions are poor

Work pressures caused by poorly trained staff, inadequate staffing levels, jokes for SOPs, the sell, sell, sell, MURs,MURs,MURs , recruit new patients recruit new patients, mentality etc need to be addressed ASAP. To be honest we all have a criminal conviction hoovering over our heads as we go about seeking our daily bread which is subject to how well we juggle our pharmaceutical responsibilities in the midst of some of the pressures I've outlined above .There but for the grace of God I go

I had an elderly gentleman ranting at me today because I refused to sell HIM canesten oral one (fluconazole) ..yes it was for him...he retorted that he'll pop into TE...O they always sell it to him once he tells the girl at the counter that he's not on any other meds. (my counter assistant refered him to me as she wasn't comfortable with the sale).

Most supermarkets particularly TESCOs are always understaffed and their glorified store /section managers are always pinching pharmacy staff to help out on the check-outs , leaving p'cists with little or no staff.
Hopefully the PharmSoc will investigate the conditions this poor p'cist had to work in and throw the book at TESCOs (highly unlikely).
Just as we had lessons to learn from the Dexamethasone case ..there are many lessons to be learnt from this one too particularly with the RP regulations looming.

[DavidS]

Well its good to see that the RPSGB have done something - they have issued a press release about decrimilising one off dispensing errors.

It doesn't cut it with me. How do you know when the next one will be? The law of averages doesn't apply to one incident. The two really disastrous errors in a pharmacists entire career might happen in the same week, particularly if its under the circumstances described here (I don't condone working under those conditions, of course).

If they want to encourage free reporting, then dispensing errors must be decriminalised completely. Even after that it won't be instant: people will want to see how the regulator treats pharmacists who make mistakes under stressful circumstances, before admitting to anything they have done themselves. So the sooner the change is made, the sooner we can make progress in protecting patients.

"Honest" errors by a competant and ethical pharmacist doing their job to the best of their ability must not be a criminal offence.

They can always go for criminal negligence, if that's what it turns out to be.

And they don't need it to be a criminal offence to strike someone off.

[Jeff]

so why aren't sanctions brought against the pct for insisting that a pharmacist be present in the pharmacy for the full 100 hours with no break,

Because we do not have a body willing or able to represent both/either pharmacists and/or pharmacy.

Jeff

[Jeff]

I make mistakes - not often! - working normal hours. so does every human being. Your post is an example of one of yours!

You missed out the preceding paragraph

Hang about - working 10 hour shifts without a break is a matter of choice.
If someone habitually makes dumb choices and it results in a danger to the public what are we supposed to do?

Does the fact that a contract insists on 10 hours without a break mean that it is unfair and hence unenforceable? I can't afford to test it, so I don't accept any of these bookings. Cue the RPSGB for a test case?

LOL the RPSGB - never - perhaps the one of the new bodies will consider the patients.

Jeff

[johnep]

Unfortunately, the people who dream up these rules work in comfortable spacious offices with tea, coffee, and lunch breaks. Always plenty of others to cover for them. They just cannot imagine that these things do not exist elsewhere.

Rather like the girl who wrote to her boyfriend in the trenches during WW1 who thought he must be glad to get back to the warm comfortable barracks after a long day in the trenches. (soldiers were often weeks at a time living in squalor, mud and rats).

johnep

[Jeff]

Please don't think retail is easy, and don't think you can walk away if everything is not exactly as it should be. You will only end up on the dole.

I'm not saying walk away - I was talking about habitually accepting unsafe practices - a 10 hour shift it everything has gone pear shaped is one thing - a 10 hour shift as a matter of course is another.

Short staff because of an unforeseen circumstance - not a lot we can do. Two people off on maternity leave - that's something the contractor knows about and can plan to deal with.

If anyone has any ideas on how to change this I'm up for just about anything.

Representation to the PDA perhaps, or the new regulatory body when it appears.

Jeff

[DavidS]

You missed out the preceding paragraph

Jeff

Oh, you are right, I did (bangs head against wall) that's what happens when I try and out-Jeff Jeff.

Still, the point I was making is that mistakes happen even on short shifts.

The last mistake I made (spotted by a technician, thank goodness, who suddenly realised she had picked the wrong strength) was about four minutes after entering a strange pharmacy as an emergency locum, with an impatient customer kicking off. Deep breath.

I do recognise that some 10 hour shifts may be as safe as some 4 hour shifts, 50 item a day pharmacies, that kind of thing. But mistakes will happen, and if a disaster occurs, the pharmacist hasn't a leg to stand on, as we have seen, and the company shouldn't have either, if they knew what's happening.

[Jeff]

David,
I accept that mistakes happen. I make more than enough.

What I cannot accept is that it is in either the patients or pharmacists bests interests for a pharmacist to habitually work under conditions that make a mistake more likely.

I am less than impressed with a profession whose reaction is to have the law changed to legalise errors and appears quite happy to ignore any/all factors which contribute to them.

Jeff

[the old merlin]

What is really needed is an sensible, informed discussion of what led up to this error, and of what happened after it.

So far, we don't know how far below "establishment" this pharmacy was on the day.
We assume, from what was said in Court, that Mrs Lee was familiar with that pharmacy. But, we assume. She might have worked in other Tesco pharmacies (which was how she got her testamonials.)
Was the Rx handwritten or printed? Probably the latter. since no-one has queried the handwriting.
What about the packaging? Were both drugs in the same manufacturers livery.

But no, the Crown Prosecution Service, anxious to get it's stat's up saw an easy "kill" and rushed ahead. Probably put the development of a "no blame" culture in the NHS back 10 years.