Re: Dispensing Errors

[DavidS]

what will the statutory committees do if the pharmacist responsible is not traceable (e.g pharmacist did not initial his/her checking initial or the prescription or label with checking initial was destroyed or vanished)

I find it irritating when I get mistakes returned to me which have not been signed at all, and, particularly thinking of one place I go to, all the staff know who it is who doesn't sign.

But I take your point, that the rather minor infringement of not completing the audit trail would be easier to deal with than making a dangerous mistake.

[lamzee]

I thought (rightly/wrongly) that regardless of who made the error, or who initialled/checked the item, that the only person liable in law is the one on duty when the item was handed out (regardless of any part played in the dispensing process). Hence the current minefield of being a locum!

Yes/no?

[roper]

The error with peppermint peptac did actually happen to me and Rowlands wrote to tell me! It seems to depend on how readily the shop staff tell tales! On the flip side, I had a complaint go all the way to the society fitness to practice team because I checked a technician dispensed script for 6 trimethoprim which hadn't got a leaflet in the packet. Patient returned to shop and got stroppy, apology and photocopy leaflet given, no report made - so no letter - but later a full PDA defense issue! Apparently, if you can't even remember the incident (because you were never aware) then you have no defense. I got a letter of advice for that one.

[DavidS]

I thought (rightly/wrongly) that regardless of who made the error, or who initialled/checked the item, that the only person liable in law is the one on duty when the item was handed out (regardless of any part played in the dispensing process). Hence the current minefield of being a locum!

Yes/no?

I would like to raise the possibility that if the locum is following acceptable SOPs (by practice, i.e. have been in use for months, and of which the regulator has had plenty of opportunity to require alteration) then s/he cannot be acting irresponsibly.

So, for instance, in a hub and spoke model where the sops require that the bag is handed out unopened at the branch, surely the pharmacist cannot be said to be acting irresponsibly by following those SOPs.

[lamzee]

SOPs re hub and spoke would not be mentioned in the medicines act though, as they hadn't been invented then.

http://www.opsi.gov.uk/acts/acts1968...9680067_en.pdf

[DavidS]

SOPs re hub and spoke would not be mentioned in the medicines act though, as they hadn't been invented then.

http://www.opsi.gov.uk/acts/acts1968...9680067_en.pdf

That was just an example, although I take your point.

Another might be where a script bagged from the previous day is handed out by a counter assistant when a different pharmacist is RP.

[johnep]

The question of PILs in split packs is a thorny one. I had a late night rota script for Levonelle and citalopram 10mg x 10. No PIL in the already split pack so I innocently asked if pt had had the nerve tablets before. Her mother exploded and had obviously thought I said 'birth' tablets. She wanted my name off my certificate and threatened all sorts. This and they had come in as we were closing and we were already 20 mins after time. I wrote an incident report but nothing happened.

In Pharmacy manager you have the facility to print out PILs and this is very useful for the diclofenac acute scripts.
johnep

[roper]

Speaking to representatives, rather than to patients directly, is another thorny issue. I would like to think that by authorising them to collect the script the patient also authorised us to discuss the treatment - but I don't think that is entirely true!

[Pharmanaut]

Speaking to representatives, rather than to patients directly, is another thorny issue. I would like to think that by authorising them to collect the script the patient also authorised us to discuss the treatment - but I don't think that is entirely true!

Just another thing you have to be careful about.

[howe928]

Statutory Committee of the Royal Pharmaceutical Society (10 December 2005)
Quote 'The patient concerned was a frail 86-year-old woman who had just been discharged from hospital. On 1 April 2004 her GP had generated a prescription for several medicines. The prescription was not passed to the patient or sent to the pharmacy. Instead, a member of the surgery staff telephoned the pharmacy, but what she read out was a prescription for several medicines for a different patient who was not known at the pharmacy.

In a subsequent telephone call, Mr Chiu was told that the medication was being changed and that the prescription was urgent. He twice sent a driver to collect the prescription but on both occasions the surgery was closed. Furthermore, the surgery’s fax machine was not working at the time.

On the next day, notwithstanding the absence of a prescription, a monitored dosage system (MDS) tray was made up. Having been told that the medication was to be changed, Mr Chiu was not put on alert by the fact that the medicines ordered did not coincide with the patient’s medication record. The medicines were supplied to the patient by the pharmacy driver on the following morning.'

This is another typical example of perfect storm. Surgery staff summoned to court? Another highlight a need to make sure people are held responsible for their job responsibility.
There is a training available for surgery staff
Developing a medicines management training package for GP receptionists | PJ Online
hopefully this will be put into practice.
Some phamacies stop taking phoned prescription, some go further not doing faxed scripts.