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  • Fatal Dispensing errors

    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???
    Kemzo the pharmacist forumly known as kemzero

  • #2
    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...
    Ze genuine Article, present & perfect!

    Comment


    • #3
      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.
      Linnear MRPharmS

      Foetal Alcohol Spectrum Disorder: The biggest cause of brain damage and 100% preventable.

      In pregnancy: 1 fag is not safe, 1 x-ray is not safe and 1 drink is not safe.



      For handy pharmacy links try
      pharmacistance.co.uk

      If you like my posts or letters in the journal try my books!
      eloquent-e-tales

      Comment


      • #4
        Originally posted by kemzero View Post
        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!
        Lively debate is encouraged but please respect the opinions and feelings of others.
        Please help keep the forum vibrant by spreading the work to friends and colleagues via word of mouth or social media.
        Thank you for contributing to this site.

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        • #5
          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...

          Comment


          • #6
            Originally posted by Linnear View Post
            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
            Kemzo the pharmacist forumly known as kemzero

            Comment


            • #7
              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
              Linnear MRPharmS

              Foetal Alcohol Spectrum Disorder: The biggest cause of brain damage and 100% preventable.

              In pregnancy: 1 fag is not safe, 1 x-ray is not safe and 1 drink is not safe.



              For handy pharmacy links try
              pharmacistance.co.uk

              If you like my posts or letters in the journal try my books!
              eloquent-e-tales

              Comment


              • #8
                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
                Kemzo the pharmacist forumly known as kemzero

                Comment


                • #9
                  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.
                  Linnear MRPharmS

                  Foetal Alcohol Spectrum Disorder: The biggest cause of brain damage and 100% preventable.

                  In pregnancy: 1 fag is not safe, 1 x-ray is not safe and 1 drink is not safe.



                  For handy pharmacy links try
                  pharmacistance.co.uk

                  If you like my posts or letters in the journal try my books!
                  eloquent-e-tales

                  Comment


                  • #10
                    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.

                    Comment


                    • #11
                      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

                      Comment


                      • #12
                        Over to you Linnear

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

                        The boots MDS thing...is mega scary!
                        Kemzo the pharmacist forumly known as kemzero

                        Comment


                        • #13
                          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

                          Comment


                          • #14
                            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.
                            Linnear MRPharmS

                            Foetal Alcohol Spectrum Disorder: The biggest cause of brain damage and 100% preventable.

                            In pregnancy: 1 fag is not safe, 1 x-ray is not safe and 1 drink is not safe.



                            For handy pharmacy links try
                            pharmacistance.co.uk

                            If you like my posts or letters in the journal try my books!
                            eloquent-e-tales

                            Comment


                            • #15
                              Originally posted by Linnear View Post
                              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!
                              Kemzo the pharmacist forumly known as kemzero

                              Comment

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