Dispensing error resulting in Jail Sentence

[trulylastniceguy]

Do you all think it is about time the Manufacturers standardise all the tablets with specific colours, tablets sizes and the boxes? I am sure majority of dipsensing errors are due to this chaotic variety?

How many lifes can we save by doing that?

How come the government spends all these money to do this and that, but not concentrates on this safe method?

If the prednisolone and propranolol have distant packagings, I am sure that would not have happened! It should be the manufacturers being charged for manslaughter and not poor Elizabeth!

[gmorris291]

As a retired pharmacist owner of an independent pharmacy, I too feel a chill running up my spine from the implications this prosecution has exposed.

I ran a very busy high dispensing pharmacy next to a surgery. I would arrive in work for eight o’clock, sort out the necessary post etc and open at nine. From then on it was like being on a conveyor belt for prescriptions. I had excellent staff and thoroughly enjoyed my time as a pharmacist. I was mentally exhausted by the end of the day and would often fall asleep for an hour after my evening meal.

One day, a close friend of mine, called into the pharmacy to speak to me. He waited in the corner of the dispensary for ages, waiting for an appropriate time to have a chat. Eventually, after seeing me deal with visiting nurses, doctors, care home staff, prescription checking, patient enquiries etc, he left without any discussion and said he would see me later.

That night he came around to my home and said something that changed my perspective on life. He said that no one should be expected to work at such a relentless pace. He had no idea what pressures exist in a busy community pharmacy, but having observed me working on many occasions, he was sure that it was both unsafe and unhealthy to be subjected to such work pressure on a daily basis.

From that point, I did take a lunch hour, and quickly I found it essential for my own well being to have the time to chill out and re-charge my batteries for the afternoon session. Yes we lost business and yes there were complaints, but I honestly found the lunch time break absolutely necessary. It was my choice, it was my profit that was lost, and it was my own sanity and the safety of the patients that I was protecting. I know that was in a very privileged position of being able to take this action and in practice we lost very few prescriptions due to the geography of the surgery and my pharmacy.

It is long past time that the Pharmaceutical Society should tackle this problem head on. It is the interests of their members as well of that of patients to ensure that pharmacists are not over-stressed by working for protracted periods without statutory breaks.

On the Chemist & Druggist website this morning I read that “ The MHRA has advised that products containing salicylate salts such as Bonjela should not be used in patients under 16 years old. The agency stressed this was a precautionary move and that there were no new safety concerns over the drugs. It emphasised that the advice was being issued due to a “theoretical risk that these products could increase the possibility of a child developing Reye’s syndrome".

If such draconian measures are taken over theoretical risks, what in heavens name has allowed the situation to continue where genuine risks of not taking appropriate breaks have been accepted for years? Worse than that, additional duties imposed by the new contract i.e. MURs, multiply the risk of error. In single handed pharmacies, attempting to perform MURs and keeping the dispensing side of the business functioning safely seem impossible.

Eventually, pharmacists will be able to vacate the premises under the Responsible Pharmacist proposals, so you will get a break of sorts eventually. “Ask the pharmacist for advice” will be abandoned during this time. Checking technicians will keep the majority of the dispensing operations functional.

However, as a pharmacist, how many times have your ears pricked up when a patient says something to one of your trained staff and you have intervened? How many times has an error jumped off the prescription due to a sixth sense that is developed with experience? How many times have you been approached by a patient with a problem that is far beyond the expertise of your staff? Try writing that into an SOP!

Do you honestly believe technicians will fulfil this role to your professional satisfaction? Who will end up in court when that dispensing error eventually occurs? For years we have promoted the knowledge, convenience and accessibility of pharmacists; now it is beginning to appear as if it was all for nothing.

In my opinion, there are too many powerful businesses involved to allow the Society to interfere with making breaks a professional requirement for pharmacist employees. Much hot air will be created on the subject, but little practical intervention will filter down to the employee pharmacist!

[Pharmanaut]

As a retired pharmacist owner of an independent pharmacy, I too feel a chill running up my spine from the implications this prosecution has exposed.

I ran a very busy high dispensing pharmacy next to a surgery. I would arrive in work for eight o’clock, sort out the necessary post etc and open at nine. From then on it was like being on a conveyor belt for prescriptions. I had excellent staff and thoroughly enjoyed my time as a pharmacist. I was mentally exhausted by the end of the day and would often fall asleep for an hour after my evening meal.

Agree with your post, we have been through the same mill by the sound of it.

My principle worry is that the conveyor belt will start to move faster once we are handling most of the prescriptions on EPS. Those who read my postings will be aware that EPS is just a messaging system, it does not fix bad prescriptions or clinical problems, it just delivers them faster. Keep your dispensing radar on. During a recent test that I was involved in it is very easy to become 'computer numb' and just press "Yes, Yes, Yes" so that you can keep up with the system. No doubt the surgery staff will be doing the same thing.....

[imaginegenerous]

I actually find this case very frightening. I feel very sorry for Ms Lee and the family involved. I've mentioned in another thread about feeling under pressure by customers and senior management to cut short my ''lunch break'' due to work piling up and how it worries me that a serious error will occur. I have a performance review with my area manager coming up next week and I certainly will be asking his opinion on this case and what it means for branches such as mine that don't close or there's no official break for the pharmacist. Like everyone else I have made errors that unfortunately have gone out to the patient. I've also picked up plenty of 'near misses' where the dispenser(s) have made an error with labelling, drug selection etc as they are also under a considerable amount of pressure to get the work done. This case has really made me think about whether I really want the pressure of something like this happening to me. I think it's about time we all voiced our opinion to the Society on the matter because if things don't change it's a horrible price to pay both for the pharmacist involved and the patient/their family.

[Defblade]

I certainly will be asking his opinion on this case and what it means for branches such as mine that don't close or there's no official break for the pharmacist.

I'd suggest going in with a copy of the Working Time Directives. I'm afraid their opinion isn't going to count for much either way tho. In fact, if you are not going to insist on your breaks at the end of it, you may as well not say anything in the first place as you'll end up with pretty much the same "troublemaker" thought running round your AM's head. Put it in writing to the SI and start looking for a new job...
... they did ask you to sign away (with your fully informed consent) your WTD rights when it came into force, right? No? I'm sure they'll really enjoy the employment tribunal

[Jeff]

Failed check system for chemotherapy leads to pharmacist’s no contest plea for involuntary manslaughter

"The April 19, 2009, Cleveland Plain Dealer covered another disconcerting report about a healthcare professional who is facing criminal charges for his role in a fatal medication error.(1) According to the news report, a former Ohio pharmacist will plead no contest next month to involuntary manslaughter of a 2-year-old child who died in 2006 as a result of a chemotherapy compounding error. We first wrote about this tragic error in our March 8, 2007 newsletter, when criminal investigation of the event was being considered.(2) Since then, the pharmacy board revoked the pharmacist’s license, and a grand jury indicted him on charges of reckless homicide and involuntary manslaughter. The pharmacist faces up to 5 years in prison."

Jeff

[johnep]

Thanks for the links, made sad reading. I have never come across 23.4% Sodium Chloride sln. Reminds me of the numerous fatalities caused by confusion of Potassium Chloride solns.
johnep

[amit]

Sorry to be a pain and post a link to an external site but I came across this group on facebook and thought it might be of interest considering the topic of conversation. Some of you might want to join:

Decriminalisation of dispensing errors. | Facebook


Why is it that we are the only profession ever prosecuted for errors?
If an accountant errs, the consumer pays.
If a judge errs, the alleged criminal pays.
If a doctor errs, we pay.
If we err, we pay.
If the patient takes the medication incorrectly, we pay.

[johnep]

The Pharmaceutical Journal Vol 263 No 7068 p662
October 23, 1999 News
This refers to a dispensing Dr who prescribed and 'supplied' ie dispensed a cytotoxic resulting in the death of a pt. Unsurprisingly, a slap on the wrist.

Why was'nt he prosecuted and given a jail sentence. One law for the Drs and another for pharmacists.

The censure was all about the prescribing, dispensing summarily dismissed out of hand as unimportant.
johnep

[Rafael]

good point John, not only they are dispensing scripts ( historical job of a pharmacist) and making a big sum out of it, they are also immune from prosecution.