Morphine in Dosett box, another death.

[johnep]

Just seen item on TV. Cambridge pharmacist struck off for writing MST 100mg instead of 10mg on Mars sheet which was then used for dispensing by a tech.

I have always insisted on checking boxes against a script rather than the mars or summary sheet

I happen to know the pharmacy where this happened. Hated calling there when a rep as always got a rude reception.

Wonder if there will now be a jail sentence?

I have worked at very busy pharmacies where separate room for trays. Not once was I asked to check a tray.
johnep

[dizzyb23]

I'm not a homes meds robot but I thought CD's weren't allowed in dosette boxes???

[bleepholder]

i have seen CDs in dosette boxes....i guess depends on how competent the patient is, and if CD was in seperate box would they remember tot ake it in combination with their other meds in the dosette box....

easy mistake to make...just not the sort of one you want to make with MST...poor chap!

would it be classed as manslaughter then?

[johnep]

Here is the link.

http://www.cambridge-news.co.uk/Home...ine-mix-up.htm

johnep

[jennimay]

thought MARS charts were used with meds dispensed ordinarily-not in dossette boxes?

[roper]

It basically sounds like the pharmacist did not check the MAR sheet against the scripts when checking off the dosette because he himself had written the details on the MAR sheet in the first place so he was effectively self checking. It is worth us all remembering that it takes more conscious effort to effectively check your own work. I suspect there will be serious consequences for this individual.

[johnep]

He was struck off yesterday and could well be manslaughter charge as errors not yet decriminalised. Consider unlikely to happen now as new govnmt will want to demonstrate it is 'tough on crime'.
johnep

[pharmer7]

funny how the dispenser "had been distracted while making up the box of drugs and had not compared the prescription with the backing sheet". I bet nothing will happen to them, even though they should really have checked it.

[bobbin]

I bet nothing will happen to them, even though they should really have checked it.

They should... but the pharmacist was responsible for checking and all pharmacists should know to check CDs thoroughly. The dispenser was probably an assistant on the minimum wage. It would be completely inappropriate for anything to happen to the dispenser, except for her to receive some further training.

[Pharmanaut]

Buck stops with Mr PharmS or Ms Pharms who was in personal control or RP I'm afraid.
We are there for a purpose.
Patient safety.