errors made by other pharmacists

[howe928]

Lately i have prevented quite a few dispensing errors by another pharmacists, one example is

a pharmacist who worked previous day bagged this patient medications up and ready for patient to collect. if the patient was served by a staff, most probably the patient would receive bagged medicines as it were. i just happened to serve this customer and opened to check each medicines with this patient, the patient said nothing new but when i looked closer one of the items dispensed was wrong.

Question 1: if you were on duty that day and your staff gave out that bagged medicines checked by another pharmacist,
do you have any responsibility at all?

Question 2: what if this involved a controlled drug e.g. Butrans or MST Continus,
do you have any responsibility at all?









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it is not easy for a pharmacist to prevent a dispensing error (medicines or appliances) checked off by another pharmacist (because it is not a common practice to re-check another pharmacist work at the current work place practice but if this unusual practice helps to improve patient safety then this kind of practice might worth further researching and encouraged or promoted to safeguiding patient safety). I think this should be recorded properly (dunno what paperwork is available at the moment, might just use dispensing error form or similar) and the statutory committees should take this into considerations when considering a case against a pharmacist (e.g. number of dispensing errors prevented and hence improved patients safety against dispensing error case in question)

Pharmacists made dispensing errors not because they want to make that error (if they were then the statutory committees can sort them out without any mercy) but it is an accident. A pharmacist checked and recorded so many items and so many things nowadays (scripts are signed properly by prescribers and patients, dated properly, prescribable under NHS, dose, form, interactions, quantity, owing, expiry date, email alerts, patients' name and address, supervised counter sales, opiods methotrexate warfarin check and record etc) and we skipped toilet trips and cup of tea or coffee always gone cold. On top of that, squeezed in a few extra paperworks to complete and MUR. Zero error expected. Patients keep asking 'how long it gonna be?' 1 minutes or less per item waiting time expected {3-5 minutes 'okay', 10 minutes 'that long?', 15 minutes '...(disappointed) i will call back (come back 10 minutes later and sit down there not letting you know)' 30 minutes 'what?!!! half an hour???!!!!!! are you serious? (obviously not amused)}

[womble]

I have never seen it done in the UK - probably due to lack of space at counters and thus lack of privacy. But where I used to work in NZ completed checked scripts were put in baskets on the shelf, and then bagged in front of the patient. This functioned both as a dispensing check, as a we got the right number of items check, and allowed the customer to perform their check at the same time that all was as they expected!

[Rafael]

does not work at prescription factories, which are usually understaffed.

[OrganOlive]

does not work at prescription factories, which are usually understaffed.

Totally agree with you

[jaymags]

[QUOTE=howe928;34414]
Question 2: what if this involved a controlled drug e.g. Butrans or MST Continus,
do you have any responsibility at all?


I would have thought that prescriptions involving Butrans and MST were not bagged up and waiting for patients to collect anyway. At least they aren't where I work, they are left in the quarantine area and are not dispensed until the patient comes in to collect.

[Pharmanaut]

[QUOTE=jaymags;34436]

Question 2: what if this involved a controlled drug e.g. Butrans or MST Continus,
do you have any responsibility at all?


I would have thought that prescriptions involving Butrans and MST were not bagged up and waiting for patients to collect anyway. At least they aren't where I work, they are left in the quarantine area and are not dispensed until the patient comes in to collect.

Prepared and ready, but kept in quarantine area.
Checked by pharmacist on duty before being handed out.
Other scripts - there can be around 100 ready to collect, checked by previous pharmacists. Could you realistically check another 100 on top of the 800 that you do in the day?

[howe928]

[QUOTE=Pharmanaut;34462]

Checked by pharmacist on duty before being handed out.
Other scripts - there can be around 100 ready to collect, checked by previous pharmacists. Could you realistically check another 100 on top of the 800 that you do in the day?

will the responsible person legislation changed anything i.e. all responsibility falls on the shoulder of the responsible person on duty that day or still the pharmacist who put signature on the checked by box who is ultimately responsible?

i can only do what i can, i alwasy give my best shot, i reviewed my checking process and learnt from my own checking errors to fine tune my checking techniques to ensure patient safety ( it also means i take more and more time checking), it was lucky to find that error by chance just like finding a fraudulent script, not everyday thing but one is very good result, the reward is huge to know that you might have save somebody from falling over or taking wrong medications

[posey]

a society inspector once told me, if you could get your pharmacy into a system where bagged prescriptions were tamper proof once sealed, then technically even if another pharmacist were to give it out the next day, a mistake within the bag would lie in the shoulders of the checker. Tamper proof being something as simple as a staple over the bag label. Hence if the staple/label looks tampered with, then it would be wise to open up the contents and re-check. The dispensary staff would need training up on this as well to notify the pharmacist if a re-check was necessary. Feasible?.. maybe...??

[Zoggite]

a society inspector once told me, if you could get your pharmacy into a system where bagged prescriptions were tamper proof once sealed, then technically even if another pharmacist were to give it out the next day, a mistake within the bag would lie in the shoulders of the checker. Tamper proof being something as simple as a staple over the bag label. Hence if the staple/label looks tampered with, then it would be wise to open up the contents and re-check. The dispensary staff would need training up on this as well to notify the pharmacist if a re-check was necessary. Feasible?.. maybe...??

That's what my SOPs say; Plus, we initial the bag label once it's stuck on and stapled to the bag, making sure we overlap onto the bag, so it's really obvious if the bag has been re-opened.

[Pharmanaut]

That's what my SOPs say; Plus, we initial the bag label once it's stuck on and stapled to the bag, making sure we overlap onto the bag, so it's really obvious if the bag has been re-opened.

We need a 'black box' recorder like they have in Aircraft.

How about a 'green cross dispensing recorder'.....

One interesting innovation would be to have a web-cam thing over your checking area. Once you have done all the checks, you then take a picture of what you are putting into the bag, which is kept in the PMR.
This would help with those 'oh my god' moments when you pick up something later and the packaging reminds of you something you did earlier. Don't want to mention details as I don't want others linking products together!

OK its a serious idea.
You could also photograph who you hand stuff out to as well...
Not sure how that would work though....

If you are one of these places where extemp disping still happens you could take a photo of the stuff on the measures and scales etc.