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Dispensing error resulting in Jail Sentence

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  • #46
    Re: Dispensing error resulting in Jail Sentence

    AS I do not really know how to put in links unless have site up at that time, have just been copying and pasting address. You will have to google.


    • #47
      Re: Dispensing error resulting in Jail Sentence

      (the links provided starting with 'former...' above do not work)

      interested to know more?

      Former locum handed suspended jail term for dispensing error - Chow Chow - Chau Chau - Yahoo! BLOG
      Demands for decriminalisation after locum sentenced for error - Chemist + Druggist
      Dispensing errors | PJ Online
      Tampa Personal Injury Attorneys | Tampa Injury Attorneys | The Distasio Law Firm
      In the United States it is highly unlikely that this type of pharmacy mistake would lead to such an extreme reaction. Simply put, such negligent conduct does not warrant criminal charges. Instead, under our system of justice, the state pharmacy board would have the right to civil remedies such as requiring continuing education classes, a civil fine, and in extreme cases, suspension of license. In addition the injured person would have a right to bring a personal injury lawsuit for monetary damages. BUT
      Tampa Personal Injury Attorneys | Tampa Injury Attorneys | The Distasio Law Firm
      Technically, I was not wrong because I stated it was "highly unlikely". However, such criminal prosecutions do in fact occur in the United States. For example, Eric Cropp, a Hospital Pharmacist, was recently charged criminally for his role in the overdose death of 2 year-old Emily Jerry. According to, Eric Cropp is about to plead no contest to charges of involuntary manslaughter.

      The *Angriest* Pharmacist | Blog Archive Save us all
      'Call me naive and old fashioned (despite being young) but i thought professional bodies were there to protect the members and promote the profession, not alienate everybody who is FORCED to pay their membership fees.'
      'One of the posters mentions the RPSGB being useless, that is very true, and thankfully it will be dead soon.'

      PDA sounds good to you?

      'This poor woman is working hard, trying her best, and makes a mistake, which HAPPENS, we are not robots and her life is ruined?

      “The chances of errors like this are increasing due to many factors.

      * High dispensing volumes
      * Inadequate staffing
      * Undertrained staff
      * Working without breaks and long shifts
      * Packaging “improved” to make errors even more likely(see “new”Ikorel)
      * Orders coming in from many sources and non continuity of brands
      * Increased demands on pharmacists’ time (MURs, minor ailments etc)
      * A multitude of computer systems and the pressures of preparing for ETP
      * A demoralised workforce”

      Solution (IDEAL WORLD):
      *quantity sacrifices quality unless a similar Good manufacturing practice (GMP) used in the factory system is in placed, repeat medications would be dispensed from a pharmacy factory just doing repeats, community pharmacies would be doing small volume scipts e.g. short term systemic treatment and topical treatment + other services e.g. MUR, AUR, Minor ailments, OTC
      *company must have a qualified staff standby at all time
      staff must be fully trained before allowed to work independently (while still undergo training - must be accompanied and supervised by a trained staff at all time)
      *compulsory rest break (not disturbing allowed) and maximum working shift in placed
      *packaging stay the same forever (hahaha) and same medication must appear only in one packaging design
      *protected time given to pharmacist to perform services or a second pharmacist system in place
      *All staff fully trained before implementation of ETP
      *Organisation fits for purpose? If not, audit and adapt it until it is right.
      Regular team building events organised by company or PCT or their Society e.g. bowling, football, paint-ball, white water rafing etc

      'We do our best, we instill all sorts of programs, policies and procedures to reduce our mistakes, but they will happen.'
      (or the failure of layered of cheeses theory)
      An error always occurs at the Perfect Storm conditions, you are checking a presciption/s, then either you are consulted to answer a query regarding an OTC sale or the phone is ringing and you are thinking is somebody going to answer the phone or you try to listen to what a dispensing technician answering a patient query over the phone or who is in the shop, your mind slips and went blank while you are carrying on checking and bagging the prescription/s up. When you got a lot of prescriptions to check or shop are flooded with patients traffic and staff is panicking you are 'slow', your mind gone again thinking about trip hazard and shoplifting.

      solution: taking care of your pharmacist/accuracy checker (label dispense and put the label on, let them know if there is any changes new increase dose or strength or quantity, top up his/her water or tea and make sure they have a break and not busy all the time, tell them it is okay and do not make a fuss or big deal about doing nothing to rest their mind) and let the pharmacist/accuracy checker checks in their own time, do not rush, no pressure; if a staff want to help to bag up, make sure you check (name of the medicines and quantity as a minimum) what you put into bag otherwise please do not offer this (putting into bag is the very last check or last line of defend - unless it would be check again when patients come in)
      Last edited by howe928; 12th, October 2009, 08:41 AM.
      i am telling you about pharmacy life in practice, together with my personal opinions i think might be better for pharmacy practices


      • #48
        Re: Dispensing error resulting in Jail Sentence

        The errors are only happening because every Rx is handed out in secret paper bags, not being explained to the customer or because morons doing our IT software highlighting meaningless interactions. Mostly. Prevent those and you'll be a long way ahead.


        • #49
          Re: Dispensing error resulting in Jail Sentence

          Here is the full text of a letter I received today from the PDA.
          It demonstrates clearly the lack of honesty and the lack of professional integrity of the Crown Prosecution Service, IMO.
          It makes error reporting a farce, and the supposed "patient safety above all" message that the DoH puts forward an outright lie.
          ================================================== =====================
          Dear David,


          Following the appeal against her prosecution under Section 85.5 of the
          Medicines Act 1968 the prosecution informed the three appeal judges that
          the CPS protocol which pharmacists were promised by the authorities was
          'imminent' could be delayed for up to a year. The protocol was to ensure
          that the police would automatically refer dispensing incidents directly
          to the regulator if gross negligence manslaughter was ruled out during
          an investigation into the death of a patient, negating the need for
          prosecution under the Medicine's Act.

          Click the following link to read about our response to the Minister and
          the Crown Prosecution Service:

          Concerns after the Elizabeth Lee Appeal Hearing - The PDA Union (reproduced below by ds)


          John Murphy

          The Pharmacists' Defence Association
          The Old Firestation
          69 Albion Street
          B1 3EA

          ================================================== ========================
          The PDA response.

          The PDA Union raises concerns with the Crown Prosecution Service and the Department of Health over Elizabeth Lee case.

          In June 2009, after the original prosecution of Elizabeth Lee for offences under Section 85.5 of the Medicines Act (wrong labelling), the PDA secured the support of the government for the idea of a Crown Prosecution Protocol (CPS). The effect of this would be that in the event that any pharmacist had been investigated for gross negligence manslaughter charges and had had this offence excluded, then the Police would no longer pursue any further offences under the Medicines Act, but would simply hand the whole case over to the professional regulator - the RPSGB.

          Talks to pursue this initiative between the Department of Health, the Crown Prosecution Service and the Director of Public Prosecutions commenced almost a year ago and since the winter of 2009, the authorities have constantly indicated that the publication of these protocols was imminent.

          As a consequence, during the Appeal hearing which was considering the conviction of Elizabeth Lee on May 26th at the Royal Court of Justice, her defence team sought, on two occasions to use the imminent release of the CPS protocols to secure a more favourable outcome?

          On the first of these occasions, the defence teams approach was going to be that the appeal may well benefit from being heard, once the CPS protocols had been released as this would have had a beneficial effect on the appeal. However, the prosecution counsel, having just conferred with the CPS legal representative told the three appeal judges that the talks on the protocols had reached an impasse and that therefore their release was not at all imminent. When probed by the judges, the prosecution team indicated that they had no idea how long it would take for release of the protocols and that it could even be as long as a year.

          As a consequence, the appeal had to proceed without their benefit. On the second occasion, the point in the appeal had been reached where it had become obvious that the original conviction for an offence under Section 85.5 (wrong labelling) was likely to be successfully overturned. The question then arose as to what was to be done with the original Section 64.1 (wrong product supplied) offence which had been left in abeyance from the original 2009 trial. The defence team argued that the judges should continue to leave this offence in abeyance, Elizabeth Lee had not previously pleaded guilty to it and that if it was left fully alone, then the effect of the CPS protocols (when they came) would mean that the CPS would not be proceeding with a prosecution.

          Had the judges agreed with this then Elizabeth Lee would have left the court with no remaining criminal conviction.

          However, the prosecution counsel acting for the CPS indicated that if the judges concurred with this suggestion, then the CPS would not be prepared to leave the Section 64.1 offence in abeyance and that they would instead initiate further criminal proceedings against Elizabeth Lee for breaches against this section of the Medicines Act.

          The judges therefore were minded to seek a retrial to determine the Section 64.1 outcome, however, they considered the fact that Elizabeth Lee had no appetite for yet more court appearances and consequently, they decided to simply substitute the overturned Section 85.5 conviction with the Section 64.1 offence subject to a guilt plea.

          According to Mark Koziol, PDA Chairman;

          "This throws a huge question mark over the whole matter of whether these CPS protocols are about to be released or not, for if, as the CPS counsel indicated in court, they are mired in some sort of an impasse between government departments, then we need to get this resolved straight away. The profession was promised these protocols, not because of some special favour from the government, but because they would help to prevent defensive pharmacy practice such as refusal to participate in error log reporting and also in more professionally risky leading edge work. It would also have produced a level playing field in terms of how other healthcare practitioners are treated once gross negligence has been excluded. It is therefore not only unreasonable to expect the profession to wait any longer, but further delays are not in the public interest as they will have the effect of seriously destabilising the profession."

          He continued;

          "if indeed there is likely to be protracted delay, then pharmacists have a right to know that their exposure to the risk of prosecution as a result of a one - off dispensing error is no less today than it was before the whole decriminalisation initiative commenced and that judging by the 'hardball' conduct of the CPS in the court of appeal, they can expect the CPS to take vigorous action against them."

          John Murphy, General Secretary of the PDA Union added;

          "The words of the CPS that they genuinely understand the need for a protocol for pharmacists and that they are actively seeking to deliver one as soon as possible does not match their actions. During the appeal hearing, they had an opportunity to embody their words into actions, they could have allowed the defence efforts to use the imminent release of the protocols to produce a more favourable outcome for Elizabeth Lee, but they chose not to. Worse still, they even told the judges that they would ensure that Elizabeth Lee would face further CPS attention in the event that the judges left her original Section 64.1 offence in abeyance - as was the request of the defence."

          He continued;

          "We have written to the Crown Prosecution Service and the Pharmacy Minister expressing our concerns in the strongest of terms. We have asked that they provide us with an accurate assessment of the current position so that we can decide upon what specific advice we can give to pharmacists in terms of how they should operate so as to lessen the risks. To instil some confidence in the process, we have also urged them to agree a fixed time frame in which to conclude this matter and to provide the profession with details. In light of what happened in the Court of Appeal, it is no longer acceptable to continue with the old message that 'the protocols are imminent'."
          ....just my opinion


          • #50
            Re: Dispensing error resulting in Jail Sentence

            I heard we have got a step closer to decriminalisation but I was reading that the only reason the sentence was suspended was as the company are to blame for via the medicines act. The poor lady is now a cleaner at a church. So in all honesty, we haven't got anywhere near to preventing dispensing errors from being criminal right.
            3rd yr pharmacy student - bath


            • #51
              Re: Dispensing error resulting in Jail Sentence

              One of the reasons why the GMC was so lenient with Drs (Harold Shipman), was that striking off would probably mean that the Dr would lose his home and marriage likely to break up. With a lady pharmacist, her husband would still be able to work and home not so likely to be lost. Just being made redundant from industry was a close call for me, although I was able to work in community the following week with a 25% reduction in pay.
              For a proprietor, then could use locums to keep business, but for an employee no such hope. NHS has procedure of suspension on full pay. No such comfort for a locum, and yet pressure is for PCT to suspend accused pharmacists. So a mere unproven accusation could lose your home.


              • #52
                Re: Dispensing error resulting in Jail Sentence

                What is the situation with decrimilisation now, I read in the pj theres a consultation on it in feb?
                3rd yr pharmacy student - bath


                • #53
                  Re: Dispensing error resulting in Jail Sentence

                  This year, next year, some time, never. Very low priority for govnmt.


                  • #54
                    Re: Dispensing error resulting in Jail Sentence

                    it's hard to be a pharmacist if not careful enough