Fatal Dispensing errors

[kemzero]

Recently an elderly woman died following an ovedose of digoxin being dispensed ( 62.5mcg required but 250mcg disp) although patient had other co-mobidities..trouble is still lurking and the coroner is yet to decide on the actual cause of death
It was dispensed & checked by a tech....but apparently the pharmacist is liable....its scary because I feel a lot of this will happen once remote supervision kicks in....what do fellow pharmacists & ACTs think???

[Zoggite]

The only saving grace for the (allegedly) responsible Phcist: he/she won't have to live with someone's death on his/her conscience, whereas the ACT will carry that moral guilt inside him/her all his/her life...

[Linnear]

If SOPs were followed I would like to know how Pharmacist is liable.

(Not having a go at you Kem I want to know)

My understanding was that ACTs take responsibility if SOPs followed.

If that not the case then I'm less happy about working with ACTs.

Could you keep us informed as to outcome or even better let us know where we can keep ourselves informed.

May well be something I might want to bring up at EPB.

[admin]

Recently an elderly woman died following an ovedose of digoxin being dispensed ( 62.5mcg required but 250mcg disp) although patient had other co-mobidities..trouble is still lurking and the coroner is yet to decide on the actual cause of death
It was dispensed & checked by a tech....but apparently the pharmacist is liable....its scary because I feel a lot of this will happen once remote supervision kicks in....what do fellow pharmacists & ACTs think???

That's terrible, and I think the problem we were all worried about. It will be interesting to see what the outcome of this case is!

[Cathedral]

An awful situation, and the worst nightmare of all pharmacists.
Are you insured in case something like this happens? I know this is not a big comfort in such cases, but...

[kemzero]

If SOPs were followed I would like to know how Pharmacist is liable.

(Not having a go at you Kem I want to know)

My understanding was that ACTs take responsibility if SOPs followed.

If that not the case then I'm less happy about working with ACTs.

Could you keep us informed as to outcome or even better let us know where we can keep ourselves informed.

May well be something I might want to bring up at EPB.

Dear Linnear
Would rather wait till case is out in public domain..its still being dealt with at PCT level (not by me though) so I do not have 100% facts , but someone has died of an overdose P'cists and ACTs are involved.....Not one to gossip!..jokes aside I am sure you guys will hear about it sooner or later ( but mistakes are happening very single day and people are dying ;I am sure the PDA have all the stats

[Linnear]

Sorry Kem.

Didn't realise, I thought you'd heard it through normal pharmacy grapevine.

Won't mention anything yet but please keep me posted when you can. By PM if you want to keep it out of public domain.

All the best

[kemzero]

Hi Linnear

.............certainly as I think that ACT and Pharmacist responsibilities must be clearly defined. I rang the PharmSoc yesterday and their advice was that a Pharmacist needs to be in personal control of the pharmacy and has delegated the task hence is responsible regardless of whether the tech is registered or not....quite scary if you ask me ...b/c I thot that was the whole point of getting techs registered... if I have done a clinical check and left the script for techs to complete why should I be culpable if an ACT has given out the wrong medicine?

.... this definitely needs airing / a lot more clarification

[Linnear]

I agree and will see if I can get this discussed as a priority at the EPB.




As a sideline we have just received the new draft of the EPB priorities.

I will post it on my site when it's been agreed for your perusal/comment.

[silnarnin]

The fact of the pharmacist is also liable doesn't surprise me. When I was working at boots, it was a question at many pharmacists lips, but we never got a clear answer from the supperintendent office. What the area managers always said was that if you followed the procedures you would be on the clear. However, legally the pharmacist is responsible for everything in the pharmacy, and if the ACT does a mistake, he is responsible.

It also poses a question when there is more than one pharmacist. Imagine that, in the monday, the prescription was clinically checked by pharmacist A. In the following day, tuesday, pharmacist B is the pharmacist in charge and the prescription is dispensed by a dispenser and checked by the ACT. The ACT doesn't notice the mistake. On the wednesday, the patient collects the medicines, but is pharmacist C in charge. Who is responsible? And imagine that A, B and C are locums. And in some stores with MDS, the locum isn't even aware that an ACT is checking prescriptions while he is in charge!!

This needs clarification by the RPSGB. However, knowing our dear society, I can imagine what they will say....

I can only hope that the pharmacists and technitians won't be prosecuted by an unintentional human error, that can happen regardless of how many SOPs one follows.

[johnep]

This situation of prelabelling was mentioned at the PDA conference. If you can't swear that you always check the label and bottom right corner of script when doing final check, then nothing on label other than the date it was generated will condemn you.
johnep

[kemzero]

Over to you Linnear

we definitely need some clarification on this matter ...and your di man!

The boots MDS thing...is mega scary!

[johnep]

So where do I find out about this. Although we had a dedicated room doing MDS I was never asked to check a tray. The volume was huge.
johnep

[Linnear]

Have had a list of stuff that I wnat covered by the EPB if you pratts voted me on and it jsut gets longer and longer!

But this is one thing that definitely needs sorting and I plan to try to get it on the agenda for our next meeting. We are pushing for more clinical roles but if we cannot delegate the other work without delegating the repsonsibility then forget the first hurdle we're not getting out of the starting gate.

[kemzero]

Have had a list of stuff that I wnat covered by the EPB if you pratts voted me on and it jsut gets longer and longer!

But this is one thing that definitely needs sorting and I plan to try to get it on the agenda for our next meeting. We are pushing for more clinical roles but if we cannot delegate the other work without delegating the repsonsibility then forget the first hurdle we're not getting out of the starting gate.

Of course WE voted you on, now get cracking mister!