Drug Errors

[Steve G]

Originally Posted by admin

It's done so easy when you're rushing isn't it. I trust you got it back and changed it? At least no harm would have probably been done if they had taken any. The problem is that with these "no win no fee" lawyers everywhere, people too often instantly see this sort of thing as easy money. They'll try to wreck your life, all for a few quid. It's a sad state of affairs.

Yeah, the delivery driver picked it up to check that we had actually made an error, and then I delivered the correct medication on my way home as its just round the corner from me. She took half a tablet three times, but no harm done. The patient was fine and happy enough when I took the correct medication round.

Kemzero: yes, it was recorded with copies sent to head office and superintendent.

[admin]

Originally Posted by kemzero

Hope it was logged on the clinical governace sheet and steps have been taken to ensure it doesn't happen again..... ouch sorry if i sound like the pharmacy police

I honestly don't know. I know he is an excellent pharmacist, but with the blame culture we live in he maybe decided against it.

[kemzero]

Dear colleagues

The judge in the recent Dexamethasone case ruled in favour of the plaintiff, unfortunately lloydspharmacy might be lumbered with a £5m compensation bill ....they are planning to appeal .
Technically the pharmacist dispensed what the Doc prescribed but the judge ruled that he did not follow company protocol (check dose suitability etc) this indicates that pharmacists have a duty of care towards patients ( which I am sure we all know) but to what extend , it was not a dispensing error , it was a clinical error which the pharmacist should have conveyed to the prescriber (judge's ruling) .....the million dollar question is how would this affect remote supervision and future community pharmacy practice if our necks are on the line for both clinical & dispensing errors ? By the way there is another similar case in the pipeline ....

[Steve G]

Originally Posted by kemzero

Dear colleagues

The judge in the recent Dexamethasone case ruled in favour of the plaintiff, unfortunately lloydspharmacy might be lumbered with a £5m compensation bill ....they are planning to appeal .
Technically the pharmacist dispensed what the Doc prescribed but the judge ruled that he did not follow company protocol (check dose suitability etc) this indicates that pharmacists have a duty of care towards patients ( which I am sure we all know) but to what extend , it was not a dispensing error , it was a clinical error which the pharmacist should have conveyed to the prescriber (judge's ruling) .....the million dollar question is how would this affect remote supervision and future community pharmacy practice if our necks are on the line for both clinical & dispensing errors ? By the way there is another similar case in the pipeline ....

Yes, it was a clinical error, but something I hadn't noticed before was that this patient had 0.5mg dexamethasone dispensed seven times before at that pharmacy. Given that history, I'd at least have a quick chat with the patient.
http://www.pjonline.com/Editorial/20...roiderror.html

[Jeff]

Originally Posted by Steve G

Yes, it was a clinical error, but something I hadn't noticed before was that this patient had 0.5mg dexamethasone dispensed seven times before at that pharmacy. Given that history, I'd at least have a quick chat with the patient.
http://www.pjonline.com/Editorial/20...roiderror.html

That would require the pharmacist to be the one doing the labelling and for the pharmacist to be labelling from the repeat screen.
Now the idea of a Lloyds pharmacist doing a MUR while the prescription was prepared and checking it at the end does not seem to be beyond imagination.
I am not aware of anything in the Lloyds proceedure manual that insists that scripts be labelled from the repeat sceen - or that the pharmacist does the labelling - but I might be mistaken.

Jeff

[Steve G]

Originally Posted by Jeff

That would require the pharmacist to be the one doing the labelling and for the pharmacist to be labelling from the repeat screen.
Now the idea of a Lloyds pharmacist doing a MUR while the prescription was prepared and checking it at the end does not seem to be beyond imagination.
I am not aware of anything in the Lloyds proceedure manual that insists that scripts be labelled from the repeat sceen - or that the pharmacist does the labelling - but I might be mistaken.

Jeff

Well in that case either the dispensing staff are morons for not putting a note on to say that the dose had increased dramatically, or the pharmacist was a moron for not telling the staff to note down any dose changes. Or the SOPs are wrong if they don't say anything about what to do when there is a dosage change. Whatever the case, someone should have picked up that the dexamethasone dose had changed.

[Jeff]

Originally Posted by Steve G

Whatever the case, someone should have picked up that the dexamethasone dose had changed.

Too much to expect a reasonably intellegent patient to notice it.

Jeff

[Steve G]

Originally Posted by Jeff

Too much to expect a reasonably intellegent patient to notice it.

Jeff

but these are rare and mythical creatures

[admin]

For my opinion...

I just can't see how you can blame the pharmacist in this. Yesterday I had a woman prescribed fexofenadine 180mg BD. When I told her I would have to phone the Dr as it was an overdose she screamed the bloody shop down. She told me her Dr would not make a mistake, he knew more about drugs then me, etc etc. I obviously stood my ground so she stormed out of the shop. Putting the patient first - very tough sometimes!

How can you phone a Dr every time a dose increases? I usually ask the patient if they know their dose has increased, but in a large volume pharmacy thats impossible. I often work for Lloyds and haven't seen anything in their SOP's about doses. I haven't the time to type every label, from a repeat screen or not, and if a dose is within the acceptable level I think it's reasonable to say that most pharmacists would dispense it.

I personally believe that the woman will have been told to go after Lloyds because Dr's are a much harder target to hit then we are, and the lawyers know that.

You can't call staff morons because they don't put a note on that a dose has increased. I have worked in one store that did over 800 items, 75 meth, and a needle ex scheme. Notes on drug increases, what kind of place gives you the time to do that? Show me it and I'll work there.

[Steve G]

moron was perhaps a bit harsh, true. But it's not difficult to just put a quick up or down arrow on the script if the dose has changed. And no, you wouldn't phone the doctor every time a dose changed, you speak to the patient first - if they don't have a clue then you consider phoning the GP.