Disciplinary panel puts sanctions on pharmacist who made errors

12/11/2009

A pharmacist who made four dispensing errors in three months must face stringent re-examination if she wants to return to practise.

Lynn Margaret Hill, of Scarborough, will have to satisfy safeguards including spot checks on her dispensing procedure, an RPSGB disciplinary meeting ruled.

Other sanctions include passing a return to practise course and providing evidence of error and near miss logs. The measures come despite Mrs Hill’s decision to retire as a practising pharmacist in October 2006.

She quit following multiple dispensing errors at Scarborough Pharmacy, Scarborough, between December 2005 and February 2006.

Errors included dispensing 30mg instead of 20mg paroxetine tablets and supplying 15mg meloxicam tablets instead of 7.5mg.

Mrs Hill said she had not been sleeping properly at the time of the errors, but did not accept this caused the incidents, the panel was told. She admitted failing to complete near miss forms and only filling in one dispensing incident report after the errors.

Mrs Hill said she had apologised to most patients affected by the errors. But a Society inspector had received a statement from one customer angered by not receiving an apology, the meeting was told.

Mrs Hill did not appear at the disciplinary meeting and was not represented. She had earlier accepted her fitness to practise is currently impaired and is on the non-practising register.

Under the RPSGB disciplinary panel ruling, should she decide to return, Mrs Hill must:

• notify the Society she wishes to return to practise

• pass a return to practise course

• demonstrate an up to date CPD points record

• comply with monthly spot checks from a Society inspector on her dispensing procedures for six months, including providing evidence of error and near miss logs

• satisfy a review of her practise at the end of this six month period by the RPSGB inspector

• never work as sole pharmacy owner or superintendent.

The conditions apply for three years.

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Comment on this Story

1. Posted by Cinnomen Achuzia, On 14/11/2009 14:26

Agree with Paul, we were categorically informed that our keeping scrupulous and up to date PSI's and near-miss records would not be used against us. If we know that our near-miss log could be used in this way (as a disciplinary tool) why on earth would we want to keep one. All it shows, is how good we were at catching these mistakes BEFORE they leave the dispensary.
I accept that not completeing adequate paperwork on any mistakes that DO reach a patient, is not acceptable, but this judgement, against a woman with 4 errors in 3 months, by a Pharmacist who by her own admission was having difficulties, seems heavy handed, and unfair, I don't see why they have imposed such sanctions onto someone who has left practice in 2006.
How is this a fair and reasonable judgement?

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2. Posted by shelton magunje, On 13/11/2009 09:44

I appreciate that the RPSGB is still a regulator but i would like to know, from those spearheading the formation of the PLB, how the new body would have assisted this pharmacist?

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3. Posted by Paul Summerfield, On 12/11/2009 21:12

According to the RPSGB own statistics, there are 250,000 dispensing errors every year, which equates to 684 errors per day or 4788 errors per week. Further, there were 40,235 practising pharmacists on the register as of August 2008, according to the RPSGB's registration statistics. Therefore there are just over 6 dispensing errors per year per pharmacist, or 1 dispensing error every 2 months.

Taking into account that the RPSGB consider that more than 1 error in 3 years to be enough to refer a pharmacist to the Investigation Committee, every practising pharmacist in the UK will be involved in 18 dispensing errors in 3 years. So why have we all not been reported and referred on to the Investigaing Committee and then the Disciplinary Committee?

Further, would the RPSGB then use the near miss logs and error logs to iompose further sanctions on our colleague? The Society have stated that they would not use such logs in this way. Also, will the inspector who will be conducting the review be different to the inspector who conducted the investigation?

This decision speaks for itself. No wonder pharmacists have lost faith.

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