dispensing error report in press

[Smithy]

anyone notice the report in the press of poor devil being threatened with jail because patient given propranolol (suspect instead of prednisolone but not sure)....
you would have thought that there would have been an objective report in the pj about this one as the prosection is not being brought by the society and the headline was the usula sensationalist stuff.

is the society supporting the pharmacist in her hour of need??? i hope i am wrong but i doubt it..

i hope that issues of workload, handwriting?? etc are brought into the open.
if the poor devil goes to prison i for one will be seeking an increase in locum fees to reflect the fact that we now have an army of pen pusher wanting to put us in court.

[JonF]

Re: dispensing error report in press

do you have a link to the report??

[ferretmanabu]

Re: dispensing error report in press

Grandmother with cancer died after 'Tesco pharmacist gave her lethal dose of wrong drugs' | Mail Online

[Rafael]

Re: dispensing error report in press

another dispensing error reached the meadia
Baby's lucky escape after blundering chemist gives mother deadly morphine prescription by mistake


Blundering chemist gives mother deadly morphine prescription for her baby | Mail Online

[jaymags]

Re: dispensing error report in press

What annoys me is the media only ever portray one side of the story. There is no mention as to whether the prescription was hand written or printed. I've seen some pretty bad hand written ones in my time, and yes I know if in doubt 'phone the prescribing doctor. One time it took us a week to query something prescribed by a hospital doctor, luckily the patient was understanding.

[kemzero]

Re: dispensing error report in press

I really feel for the young lady in question

Its every p'cists' nightmare

Multiples putting pressure on staff, pressure to work faster than the speed of light, customers wanting to shoot in and out of the shop under 2 mins...the list is endless

Clinical appropriateness and accuracy are paramount .A pharmacist can get done for both

1.Dexamethasone case
2.This unfortunate case.

The dispensing role has been cheapened by contractors wanting increased volume at any cost, what about quality

Its a sad sad day for pharmacy particularly p'cists as this case amongst others highlights just how vunerable we are and just how important the now "trivialised" dispensing role is.
As for remote supervision, the jury's still out, personally If p'cists are to carry the can, I ain't going nowhere

[ramroum]

Re: dispensing error report in press

It is time that the RPSGB intervene and take some measures to protect pharmacists from the huge pressure and stress put on them by their employers. The society needs to address the long daily hours pharmacists do, standing up on their feet all day concentrating on checking hundreds of medicines clinically and for accuracy.
Other pressures such as MURs. The society should ask employers to get a second pharmacist (e.g. a locum) to cover the dispensary while the other pharmacist is conducting MURs, this could be done as a session weekly(booking few patients on a specific day of the week).
Unfortunately our society just tell us what we must do, but never think of what our employers must do to ease pressure put on us

[the old merlin]

Re: dispensing error report in press

One case a multiple, the other an independent.

Can't imagine anyone giving a CD (I know Oramorph isn't, but it's usually treated as such) to a child, though.

Did once give a CD to a patient (adult) instead of non CD. Many, many years ago, when newly qualified. Dromoran (analgesic) for Dramamine (anti-nauseant). Handwritten Rx, GP's handwriting appalling, and GP had, by time Rx was presented, gone home.

Carefully questioned patient, told that he was suffering severe gut pain. Decided on analgesic. Checked with GP again next day. No, s/b anti-nauseant.

Round to house, apologise, explain, replace. Endorse CD register.

Two days later patient came in again. Could he have the original medication? That had worked for pain, prescribed one hadn't!

[Part Timer]

Re: dispensing error report in press

And this one?

Fined £2k by a magistrates court even though the inquest said the error "had not played a part" in the death of the patient, and only after the court case do the Society get their hands on it? What on earth?

[Fleegle]

Re: dispensing error report in press

Yes..usual course of events I'm afraid. Lambeth will now cry "havoc" and let slip their legal pit-bulls in order to save face, and the girls will be hit again, this time by the people whose wages they pay. Class act isn't it? In recent stat-com cases, however, the presiding "judge" has recognised the possibility of a double-jeopardy case arising, and has dealt with it accordingly. The legal fees for the pharmacist are often crippling though, as it appears that they require to defend what essentially is the same case twice.

[SolomonQ]

Re: dispensing error report in press

Morphine for baby in drug blunder (From The Argus)

ok, how can you mix a distinct pak such as oramorph with say any liquid pack never mind omeprazole liquid, either the pharmacist was highly incompetant or something fishy might have been going on e.g. "Remote Supervision"


also take a look at the daily mails take on this : http://www.dailymail.co.uk/news/arti...n-mistake.html

[kemzero]

Re: dispensing error report in press

Mistakes do happen and they can happen to you

So may external factors have been shown to be a contributing factor
but the following don't help

Pushy customers
Understaffed pharmacies
Poorly trained staff
One person being involved in the whole dispensing process e.g Pharmacist from start to finish.

Remote supervision will be every pharmacists worst nightmare , if POMs are allowed to be dispensed in our absence (e.g checking or sighting via videolink or other visuals, how can you be 100% certain , if screen is hazy or if you are concentrating on something else?

[the old merlin]

Re: dispensing error report in press

Yes..usual course of events I'm afraid. Lambeth will now cry "havoc" and let slip their legal pit-bulls in order to save face, and the girls will be hit again, this time by the people whose wages they pay. Class act isn't it? In recent stat-com cases, however, the presiding "judge" has recognised the possibility of a double-jeopardy case arising, and has dealt with it accordingly. The legal fees for the pharmacist are often crippling though, as it appears that they require to defend what essentially is the same case twice.

Not quite right in the "fine" case. I understand that the SAME lawyers represented both the employer and the pharmacist (and the technician), and it appeared that some sort of plea bargaining went on. This appears (I say appears because I'm relying on hearsay and the Press) to have meant that there was a "guilty" plea, and no discussion of the surrounding circumstances. It would also suggest that the employer paid the costs! No idea about the fine. Not even guessing, but IF the employer did, would suggest to me that higher management had some sort of "conscience" (I know, I know) about the reasons for the error.

Whether or not, when the Stat Comm will dig into that aspect obviously I don't know. One can only hope!
The Peppermint Water case wasn't reassuring on that, but maybe lessons have been learned!

[the old merlin]

Re: dispensing error report in press

Morphine for baby in drug blunder (From The Argus)

ok, how can you mix a distinct pak such as oramorph with say any liquid pack never mind omeprazole liquid, either the pharmacist was highly incompetant or something fishy might have been going on e.g. "Remote Supervision"

]

My thoughts exactly. I know Oramorph isn't legally a CD but it's very often treated as such.

[SolomonQ]

Re: dispensing error report in press

Mistakes do happen and they can happen to you

According to me Boehringer Ingelheim only have one oral solution pack with that colour scheme, (They only do two solutions-oramorph+Alupent) and their packaging is quite distinct, morphine sulphate liquid does not come in any other form. so how much negligence would it have taken for this mistake. All the excuses given in this case arent sufficient.

If the pharmacist gave out ramipril 10mg instead of ramipril 5mg, then maybe there would be some case, but not in this case in my opinion. One good example would be Teva's Prednisolone 5mg and Atenolol 50mg, both have exactly the same colour scheme.