Who is responsible? Who will be prosecuted?

[howe928]

On Monday, Patient A had handed in two prescriptions to a pharmacy staff C when pharmacist 1 was on duty, one for herself and one for Patient B. The prescriptions were dispensed the next day (Tuesday) when Pharmacist 2 is on duty. Patient A’s medicines were correctly prepared by dispenser E but incorrectly labelled by dispenser F with Patient B’s name. These items were put in the prescription bag containing Patient B’s medicines. The prescription bag containing both patients’ medicine was then checked on Wednesday by Pharmacist 3 and put ready for collection. A locum, Pharmacist 4 was on duty on Thursday, who made no checks before allowing the pharmacy staff H handed the dispensed medicines bag out to Carer D.

Is pharmacy staff C responsible for this error?
Has Pharmacist 1 got duty of care to the patient?
Has Pharmacist 2 got duty of care to the patient?
If Pharmacist 4 opened the prescription bag and checked with (final check face to face with patient was offered but patient A and B were not there) Carer D and Carer D has not got a clue, is patient A and B ultimately responsible for the dispensed medicines because patient A and B should have mentioned to pharmacy staff C that she has got a prescriptionfor Patient A and another prescription for patient B.

[roper]

Or have they breached patient confidentiality by discussing the medication with carer D?

[howe928]

Statutory Committee of the Royal Pharmaceutical Society (16 September 2006)
'He generated two dispensing labels but could not dispense the pergolide because he did not have it in stock. He intended that the product should be ordered that day from the company’s wholesaler, but the order placed with the wholesalers was for Celance, a proprietary brand of pergolide, at a strength of 1mg (1,000µg) rather than 50µg.

When the Celance arrived from the wholesaler, the labels Mr Woodroffe had generated were fixed by a non-pharmacist assistant to two boxes of 100 Celance 1mg tablets. Mr Woodroffe checked the boxes but failed to note that the wrong strength had been selected.

It was, however, a single error in some 30 years of practice and the committee would restrict its sanction to that of a reprimand.'


hmmm....do you all check all the labels generated waiting for stocks before the end of your working day shift?

http://www.pharmj.com/Editorial/2006...nt/lett07.html
'Was pharmacist really unfit to practise?'
Quote 'Given the likelihood of any “competent” pharmacist making a single accuracy checking error over a similar time, I would suggest that if judged by the the same standard, the vast majority of the profession would equally be regarded as unfit to practise. Perhaps the committee needs to consider such cases in the context of the true frequency and nature of dispensing errors in the real world and review the criteria by which it judges pharmacists as fit, or otherwise, to practise.'
Quote 'I do not think many pharmacists reading this Statutory Committee report will now want to be open or want to share their errors so they can be analysed to help prevent a recurrence.'

i agreed with Mark and Paul here,
this is a reason why NOT to report dispensing error is a wiser move, what is their protocol?
1) no reported error in the pass- reprimand or warning letter
2) a few errors in the pass - strike off
are they not interested to see if the pharmacist has improved practice and learnt from previous dispensing error/s?
practice makes perfect unless you got a accuracy checking robot - extend accuracy check training time is the way forward?

[roper]

I do make a BIG fuss if expected to check stock against a label or owing and not able to confirm with the original script or a photocopy. This is why!

[exSAgrad]

In this case, as important to see what's hidden under the label!

[Fleegle]

it is time for the answer, you might be in for a shock!
'http://www.pharmj.com/Editorial/20040703/society/p35accountable.html

Example 1 Pharmacist E undertakes a clinical check of a prescription but fails to identify that the prescriber has ordered an overdose of a particular drug. The medicines are assembled, dispensed, checked and bagged up by adequately trained technicians. The medicines are then supplied to the patient by Pharmacist F who has the details of the prescription in front of him but who also fails to identify the overdose.

Who is professionally liable in these circumstances? Both pharmacists have a duty of care to the patient and both are professionally accountable for those parts of the dispensing process for which they are responsible. In the absence of written standard operating procedures (SOPs) defining individual responsibilities, both pharmacists are likely to be professionally accountable.

Example 2 The second scenario is identical to the first except that the pharmacy has written procedures. According to these procedures, the first pharmacist accepts responsibility for undertaking the clinical check and there is an audit trail to identify the responsible professional for each part of the dispensing process. Who is liable professionally in these circumstances?

Both pharmacists have a duty of care to the patient and both are professionally accountable for those parts of the dispensing process that they take responsibility for. Here there are clear lines of responsibility and clear audit trails identifying each professional accountable for each stage of the process. However, the second pharmacist accepts responsibility for supplying the medicine to the patient and has access to the prescription at the time of supply.

It is still likely that both pharmacists would be professionally accountable. However, the presence of written procedures identifying the responsibilities of each professional coupled with a comprehensive audit trail throughout the dispensing process may mitigate the second pharmacist’s professional accountability on the basis that he should have been entitled to rely on his colleague’s skill and competence to undertake the clinical check (see below for further comment on competence).

Example 3 The third scenario is identical to the second, but Pharmacist F does not have access to the patient’s prescription. In these circumstances, both pharmacists have a duty of care to the patient and both are professionally accountable for those parts of the dispensing process that they are responsible for.

Again, there are clear lines of responsibility and clear audit trails. However, because the supplying pharmacist does not have the prescription when handing over the dispensed medicines it is arguable that he is entitled to rely on the skills and competence of his colleague who has undertaken the clinical check of the prescription.

From the three scenarios, it is clear that responsibility and accountability is a ques-tion of degree. Sometimes responsibilities are clear but more often there is a blurring of the lines between individuals’ responsibilities.

In the case before the Committee it was decided that an advisory letter should be issued to Pharmacist D, which outlined his professional responsibilities in relation to the supply of medicines. A harsher view was taken of Pharmacist C in the light of his recent previous history of dispensing errors.

Individual cases are looked at on their merits.'

according to the above, all presciptions should only be handed out and checked with patients or carers item by item by the pharmacist on duty (dispenser or pharmacy assistant would only be allowed to retrive bagged medicines to pharmacists on duty but not giving it out to patients or carers) no matter how busy the pharmacist is at that moment ('resonable promptness' according to the NHS contract and 'now' according to patients' patience)

the outcome clearly demonstrated the current pharmacy practice needs to be overhauled if the authority wants to prevent this from happening again, e.g. release a standard operating procudere to ask all pharmacists to check bagged medicines in front of patients or carers (default automatic consent given by patients) who know about patient medications

Your link doesn't appear to work...please re-post with a working link.

[howe928]

links do not work forever and i do not have time to keep checking them, that's why i copy the main juicy bits to my message, some says why not just give the link, now you can see why and why it is good to extract it and put them in your message

i checked the link, it is still working, lol

[SolomonQ]

when staff hand me a label for an enquiry e.g. what's this, where do we keep these, I shove it back and grab the prescription off them.

labels mean nothing to me unless on a box. Dispensing off labels ignores the potential labelling errors.

Also i know it's not good practice but I generally ignore the presence or accuracy of labels for "devices" that don't come with a specific direction on how to use, check against Rx make sure it's what the patient wanted. examples would be ensure drinks, doctors tend to write just the one flavour on Rx but the patient wants various flavours so im generally happy with "Strawberry" labels crossed out.

[salwal25]

This is taken from a reference and it happened in real practice too

'Patient A had handed in two prescriptions to a pharmacy, one for herself and one for Patient B. The prescriptions were dispensed the next day by Pharmacist C. Patient A’s medicines were correctly prepared but incorrectly labelled with Patient B’s name. These items were put in the prescription bag containing Patient B’s medicines. The prescription bag containing both patients’ medicine was then put ready for collection.

A locum, Pharmacist D, who made no checks before supplying the dispensed medicines, handed the bag out the following day.'

I personally think everyone that is involved in the process of dispensing and handling the prescription had a part to play.

1. when the medications were dispensed. for every prescription you should check name on the prescription ( as we all know GP surgery can get that wrong sometimes)
2.Before the medications where put ready for collection the Pharmacist C should have checked the name on the prescription against the label
3. Pharmacist D should have checked and gone through the medications with the patient. ( the patient might have realised that a mistake has been made? As not when the medications is given out that the prescription is filed right?)

Just my opinion.

[sparkybw]

What should happen in the case of a prescription that has been correctly dispensed and labelled but is then handed to the wrong patient.