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  • dispensing errors

    im concerned I may have given wrong strength prednisolone, lower than intended. i dont know for sure but im not there till next week.tried to contact patient but number surgery gave me was incorrect. hopefully they will notice if there has been an error. I don't want to get struck off

  • #2
    Re: dispensing errors

    If you have the patient's address you may wish to go round yourself or get one of the pharmacy staff to do so?

    My (extensive!) experience of dispensing errors is that most patients/families are fine when you come clean and admit it.

    You are unlikely to be struck off unless there is a serious incident resulting which is unlikely given what you have said happened. But get round as soon as you can and get the offending item in your hands as soon as possible.
    http://uk.youtube.com/watch?v=Hmbyj0XFUhA

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    • #3
      Re: dispensing errors

      Sound advice Tony.

      If the prednisolone was prescribed as the usual "reducing dose" for acute inflammation, then absolutely no harm done.

      If however prescribed as part of an anti-rejection regimen, for example, I would be a bit more concerned.

      My opinion.

      Fleeg.
      Don't Stop Believing

      http://youtube.com/watch?v=rnT7nYbCSvM

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      • #4
        Re: dispensing errors

        You can do a stocktake and check whether you've used the wrong strength..hope your dispensary stocks are kept as accurate as possible. The quicker you deal with your errors the better.

        At the end you have the obligation to follow your SOP.

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        • #5
          Re: dispensing errors

          Originally posted by Shwampa View Post
          You can do a stocktake and check whether you've used the wrong strength..hope your dispensary stocks are kept as accurate as possible. The quicker you deal with your errors the better.

          At the end you have the obligation to follow your SOP.
          Your obligation to the patient is greater than your obligation to a SOP.

          SOPs are tools not Gods to whom devotion should be paid. They don't rule our lives if we are autonomous professionals. They do if we are support staff. If an error is made get out and see what damage is done, minimise it and grovel.

          SOPs? Bah! (stumps of grumbling darkly...........)
          http://uk.youtube.com/watch?v=Hmbyj0XFUhA

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          • #6
            Re: dispensing errors

            You're scarring me Tony..I hope your SOPs put the patient first. There's a problem somewhere that a young pharmacist has to express his worries and what to do about a dispensing error to a forum.

            Don't tell me the standards of pharmacy have dropped that low in the UK that you minimise the importance of having SOPs in place.

            Comment


            • #7
              Re: dispensing errors

              Don't tell me that standards in pharmacy have dropped so low in your country that trained pharmacists need a SOP to decide what to do when they drop a clanger?
              http://uk.youtube.com/watch?v=Hmbyj0XFUhA

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              • #8
                Re: dispensing errors

                There are too many sops in my opinion. We have always had sops but not written down. Sops used to be what we called common sense. A sop for this a sop for that I'm all SOPped out.
                Make some one smile today.

                Comment


                • #9
                  Re: dispensing errors

                  Originally posted by Shwampa View Post

                  Don't tell me the standards of pharmacy have dropped that low in the UK that you minimise the importance of having SOPs in place.
                  So you have a SOP entry to refer to for every imaginable dispensing error which may occur, to be followed robotically no matter the circumstances? I doubt it..
                  I hope you never have to start making your own professional decisions or you may end up working in the EU, like Dan Carter!
                  Last edited by Fleegle; 15, October 2008, 06:23 PM.
                  Don't Stop Believing

                  http://youtube.com/watch?v=rnT7nYbCSvM

                  Comment


                  • #10
                    Re: dispensing errors

                    Originally posted by Shwampa View Post
                    You're scarring me Tony..I hope your SOPs put the patient first.
                    Tonys' probably do - but usually they are just to cover the contractor.

                    Jeff

                    Comment


                    • #11
                      Re: dispensing errors

                      Originally posted by jaymags View Post
                      There are too many sops in my opinion. We have always had sops but not written down. Sops used to be what we called common sense. A sop for this a sop for that I'm all SOPped out.
                      My point exactly.
                      Don't Stop Believing

                      http://youtube.com/watch?v=rnT7nYbCSvM

                      Comment


                      • #12
                        Re: dispensing errors

                        The point of an SOP is not to provide an exaustive set of instructions to use in every possible situation but to standardise a process so that everyone does it the same way, and that collective experiences can be used to amend them, so that an SOP is always evolving. In the case of a dispensing error, an SOP would ensure that the patient does not get even more confused because everyone is telling them something different, and the experience could be used to review the SOP for next time. It is, however, no substitute for professional judgement and over-reliance on SOPs with no willingness to deviate from them produces an out of date SOP and an out of touch pharmacist.
                        MUR

                        Major Underestimation of Resources

                        Comment


                        • #13
                          Re: dispensing errors

                          Originally posted by Jen the 3rd View Post
                          The point of an SOP is not to provide an exaustive set of instructions to use in every possible situation but to standardise a process so that everyone does it the same way, and that collective experiences can be used to amend them, so that an SOP is always evolving. In the case of a dispensing error, an SOP would ensure that the patient does not get even more confused because everyone is telling them something different, and the experience could be used to review the SOP for next time. It is, however, no substitute for professional judgement and over-reliance on SOPs with no willingness to deviate from them produces an out of date SOP and an out of touch pharmacist.
                          The point of some SOPs is simply to be used as a tool to beat the pharmacist over the head with and for a company to disavow involvement when a pharmacist has exercised their professional judgement in a situation (normally involving a grey area in the law). Remember that some company indemnity schemes do not cover you if you deviate even slightly from their SOPs - even if they are written hopelessly wrong! Make sure you take out your own insurance even if you're an employee pharmacist - otherwise you could well find yourself on your own - even if it can be seen that you were doing the right thing...
                          And if you think an SOP in particular is a great big pile of poop, come up with an alternative suggestion and let your super know - if it's good then that crappy SOP might even get re-written after your input!
                          “It's not worth doing something unless you were doing something that someone, somewhere, would much rather you weren't doing.”

                          Terry Pratchett

                          Comment


                          • #14
                            Re: dispensing errors

                            Can any of us honestly say that we remember word for word our sops? My best guess is that we all have a rough idea of what they say and know what we should be doing. Most dispensing errors never get to the patient any way but still have to be logged as near misses where I work. The mistakes are usually made because the whole of the prescription has not been read properly. The addition of an extra word on the second line can make a difference of dispensing pholcodeine linctus when it should have been pholcodeine linctus strong. We are all human and no amount of sops will ever stop human error.
                            Make some one smile today.

                            Comment


                            • #15
                              Re: dispensing errors

                              A SOP is a document. Albeit hopefully well thought out and regularly updated. There are many uses for such a document, some documented here including some sinister possibilities.

                              However, in the situation presented, a dispensing error, it is my belief that a pharmacist has a duty to the patient that over rides everything and I would expect a pharmacist in that position to contact the patient immediately. The thread originator posted that he was concerned that the telephone number supplied was wrong. The next thing to do is to drive to the patient's house, put a note through the letterbox, anything that gets the patient in contact.

                              Then you can read the SOP.

                              We are supposed to be autonomous professional people. SOPs should not be necessary for autonomous professional people. However history has proved that they are necessary in some circumstances eg infrequently encountered situations and situations where a particular company employee has specialist knowledge. This may be a health and safety issue or at least something divorced from everyday life. A dispensing error is top of most pharmacists "nightmare list" so, whilst a SOP may be necessary as a "tick box" exercise I would be shocked if a pharmacist needed to consult a SOP before acting in the interests of the patient.

                              What I am still ticked off about is the impression our colonial cousin gave when he implied that the development of a profession could be gauged by how many documents were produced to guide it's members. However he also went further and implied that UK pharmacists could be castigated for not enthusiastically adopting a rainforest destroying policy where we don't need to think because our moves have already been choreographed for us in a SOP.

                              Professional people are supposed to know what they are doing and to act appropriately in frequently encountered situations. They are paid accordingly and they have the respect of their peers for these reasons.

                              If New Zealand pharmacists believe their contribution towards the development of the profession is to write SOPs then I despair. They are, if our colleague is to be believed, regressing and if anything making their "profession" that of an ACT.

                              And then we enter the debate around why we don't reciprocally accept each other's pharmacy qualifications anymore.................?
                              http://uk.youtube.com/watch?v=Hmbyj0XFUhA

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