reporting of dispensing errors and fear of litigation

[the old merlin]

Thanks.
It did say that the Inspectors could no longer issue "informal" warnings. Which is typical of the times in which we live, and a pity.

In all my years I've only had one of those, a long time ago, but I've been involved in a few Service Committee cases, both as member and as "prisoners friend".

And it's there but for the grace of god on occasion!!!!!

And the report's right; can be frightening for the pharmacist.

[Pharmanaut]

Has anyone, RPSGB/PDA/whoever analysed these "fitness to practice complaint" figures?
If Web Ferret is right, that's a big workload for the investigators.

• How many of these were justified by a "finding"?
• How many were as a result of over zealous reporting?
• How many were as a result of area managers covering their backs?
• And if there are a lot of "silly" cases, how many of those reports were by the same person?

As someone said, somewhere, I think we should be told!



That's quite alarming. I used to think (25 years ago) that I ran a busy pharmacy and we did ca 400 per day. Lot of over-the-counter counselling on medication sales, too.

In those days it was all Diuretic + Beta-blocker and a 3 item script was about the biggest. These days its diuretic, ACE, statin, calc-channel, and ISMN minimum.

How about a 3 items or less hatch at the dispensary?

[the old merlin]

In those days it was all Diuretic + Beta-blocker and a 3 item script was about the biggest. These days its diuretic, ACE, statin, calc-channel, and ISMN minimum.

How about a 3 items or less hatch at the dispensary?

If I recall right, 14 items on one script was the biggest I saw. And, remember, they were all handwritten then!

[Linnear]

Scary message from Mark Koziol in C&D last week.

Putting wrong label on a box = 2 errors.

1) mislabelling
2) Giving out


How bad is that?

May well be bringing up at EPB.

[Zoggite]

Scary message from Mark Koziol in C&D last week.

Putting wrong label on a box = 2 errors.

1) mislabelling
2) Giving out

Add to that the charge of fraud, as you'll be claiming payment for something that you didn't actually dispense!!!

[the old merlin]

Putting wrong label on a box = 2 errors.

1) mislabelling
2) Giving out


How bad is that?

May well be bringing up at EPB.

Sorry, Linnear, but surely it is two; wrong dispensing, and poor checking. But, and it's a big big but, if it was an isolated incident then I wouldn't, from a monitoring point of view, worry about it. If there was a similar dual incident once a week (or something like that) I'd be more concerned. It would be evidence, in my mind, of a poor system.

I see absolutely no reason to pick someone up for an isolated incident, espcially one which, if picked up by the end user, had been dealt with properly. I also see no reason to pick someone up if mislabelling, for instance, is happening but the checking system's working, provided that there's evidence that the person mislabelling has been warned, retrained or something.

What I'm hearing from the grouses on this Forum is that no-one appears to have thought through a sensible inspection system!

[Rafael]

"Last month I was faxed a script for 10 oxytocin 10mg/1ml vials,one injection to be given i.m. daily, for an 85-year-old male(!) diabetic patient; I spent an hour and a half trying to get past the surgery's recorded message telling me that all their receptionists were busy, please hold the line etc...; when I finally got through, I was passed on to 3 different people before someone understood what I was querying; They promised to get back to me about it, but as it was friday...
Funnily enough, on the following monday I received a script for the same patient for oxycontin 10mg tablets, signed by a different doctor; coincidence?
Needless to say, I'm still waiting to hear from the GP who signed the first faxed script...!"

OK this might sound a stupid question but well i am still a student.
i remmember reading in the MEP that a faxed Rx is not classified as a legal RX as its not written in ink and it lacks the legal signiture of practitioner. But i also understood from MEP that we can dispense a faxed Rx if it comes from a known source" ex; a GP known to the pharmacist".

did i miss anything or am i right? how often you get faxed Rx to be dispensed and if so what do you do to assure it's safe and written by a practitioner? maybe call him and ask about it? and shall we ask him/her for a proper Rx form to be delivered to the pharmacy? why we have to dispense faxed Rx if EPS is being used?

Kind regards

[Web Ferret]

Unless you know the prescriber and the patient has had the meds before be very wary of faxed scripts - they are not worth the paper they are written on.
If a doctor (not a receptionist) wants to phone through a script - thats fine.

[DavidS]

Someone unpacking the oder has put a packet of 28 APS metoprolol 50 on the 28 APS metformin 500 pile - and the metoprolol appears on the dispensary bench in the middle of a dozen packets of metformin.

Sources of error could include sourcing both metformin and metoprolol from APS, using pack sizes of 28 for both, the arrangement of stock in the dispensary, as well as telling someone to be more careful when puttiing away the orders.

Why wait until you've given them out before addressing the potential for error?

Jeff

One of the worst mistakes I made was a few years ago now for some specialist babyfood: it had been ordered specially for the patient, and when the mother came to collect it we dispensed it straight out of the order to her. Fortunately she had more sense than I did, and checked it carefully before feeding it to her baby. It transpired that it was the third time that this error had occurred to her.

[Rafael]

"I have heard some staff say they do this on the instruction of their regular pharmacist, so they don't have to turn the pack round the other way to do a check. They place the label just below the drug name etc, so your eyes can just look at the pack, then the pharmacy label. This seems silly to me, and I wonder if others have any feelings on this subject."

we do the same in the pharmacy where i work for, thanks for bringing up this point, i will discuss it on monday with the other staff member and the "locum" present.


zogitta " Is it legal?
you are then also masking the license number , batch number, and the expiry date (unless you have erudite patients who know what "scadenza" means!).
I certainly don't allow any of that sort of behaviour in my Dispensary, thank you very much"

never thought about it this way, i guess you have a point here.