7-month suspension for pharmacist whose dispensing error led to death

Martin White (3062R) said propranolol was “side by side” with prednisolone on the dispensary shelf
Martin White (3062R) said propranolol was “side by side” with prednisolone on the dispensary shelf

A Northern Irish pharmacist convicted for a dispensing error which led to the death of a patient has been suspended for seven months.

In February 2014, Antrim pharmacist Martin White (registration number 3062R) accidentally dispensed propranolol instead of prednisolone to a 67-year-old patient, who died shortly after taking the medication, a Pharmaceutical Society of Northern Ireland (PSNI) statutory committee heard in a hearing which ended on September 28, 2017.

The regulator acknowledged that Mr White – who was sentenced to four months’ imprisonment, suspended for two years, in December 2016 – had made an “isolated incident in an otherwise unblemished career” and had been “open and transparent” during the investigation into the patient’s death.

But it concluded that as Mr White – who did not attend the hearing – had not provided any “meaningful evidence concerning his insight and the steps he would take to ensure” a similar error would not be repeated, it was “necessary to apply a sanction” to his registration.

Label mistakenly attached to wrong box

Mr White was working as pharmacy manager and responsible pharmacist at Clear Pharmacy, based at Antrim Health Centre, on February 6, 2014 when the patient’s husband presented the prescription for his wife, PSNI heard.

The prescription label directed that eight tablets of prednisolone 40mg be taken daily for five days, but this had been mistakenly attached to a box of propranolol 40mg, which Mr White then dispensed to the husband, the regulator heard.

Later that day, the patient – who suffered from chronic obstructive pulmonary disease (COPD) – took eight tablets of “what she believed to be the prescribed medication, and quickly fell ill”, PSNI heard. She was taken to hospital, where she died “a short time later” as “a result of the toxic effects” of taking the beta blocker, it heard.

Medicines kept side by side

Mr White “admitted that he had filled the prescription and that he must have mistakenly picked up” the propranolol, which he stated was “side by side” with the prednisolone on the dispensary shelf, PSNI heard.

He also “stated he had carried out checks in respect of the safe dispensing of medication in accordance with the standard operation procedures (SOPs) then in force” at the pharmacy, the regulator heard.

Mr White continued working at Clear Pharmacy – with some periods of absence due to health issues – until his resignation in January 2016, PSNI noted. During this period he had been directed by his employer not to conduct accuracy checks.

In October of that year, he was convicted at Antrim Crown Court on a guilty plea of an offence contrary to sections 64(1) and 67(2) of the Medicines Act 1968.

“No evidence of reckless” action

The regulator noted that “there was no evidence that Mr White had acted in a deliberate, reckless or wilful fashion when he dispensed the wrong medication”.

“He had been completely open and honest in accepting in subsequent enquiries that he had been responsible” for the dispensing error, it said.

“There was evidence that propranolol and the correct medication had been arranged alphabetically in the dispensary, with no warnings in place to differentiate one from another,” the regulator.

While the pharmacy’s SOPs contained an explicit requirement for “the medication [to be] finally checked by a second person”, this had been introduced “only a few days before” the incident took place, PSNI noted.

The pharmacy’s superintendent confirmed to PSNI that there would have been “insufficient time to implement the new SOPs before the picking error occurred”.

The regulator noted that in the three months following the incident, the pharmacy’s SOPs had been amended twice “to enhance the accuracy and checking of prescribed medication”.

A system had also been introduced across the 31-branch chain to ensure “all beta blockers [are] segregated into a specific section of the dispensary”, and “audible and visual alerts [have] been introduced to highlight extra care [is] needed before such medication [is] dispensed”.

Failing to offer advice

Mr White had not had contact with the patient or her husband “to offer patient advice prior to, or after, dispensing the medication”, PSNI noted. This “would have been expected, given [the] patient’s [COPD] and the fact this was the first occasion [she] had been prescribed prednisolone”, it said.

“If this had occurred as it should have done, it would have provided an opportunity to identify the error,” the regulator concluded.

“Mr White’s actions – the result of human error – led in turn directly to [the] patient’s death,” it said.

”Errors occur in busy pharmacies”

The committee acknowledged that dispensing errors such as Mr White’s “can occur in a busy pharmacy practice”. “The vast majority of these are picked up without untoward incident,” it said.

The pharmacy’s superintendent informed PSNI that Mr White had “fully realised the severity of what had happened”. However, due to his phased return to work and subsequent resignation, “it was difficult to conduct meaningful remedial work” with him, it heard.

The regulator also noted Mr White had experienced “some health issues before and after the error”, but he had “not asserted” these had “caused or contributed” to it.

Mr White had “cooperated at all stages with the investigation by his employer into the tragic death” and had “pleaded guilty at the first opportunity”, PSNI noted.

It also heard that Mr White had “expressed remorse and regret for his actions”. Although references from “various healthcare and other professionals” asserted he was “a safe and effective clinician”, since the incident Mr White had stressed it was “impossible” for him to “conceive that he could practise again”.

“Easily remedial” error

The committee was satisfied that despite the specific circumstances surrounding the error amounting to “misconduct”, the error “was easily remediable” by “robust personal training and reflection”. However, as Mr White had not engaged with the committee, there was “no meaningful evidence” that he had “demonstrated insight”.

“For these reasons, there [is] a risk the error could be repeated,” it concluded.

Striking off Mr White “would be a disproportionate sanction”, said the committee, which ruled instead to suspend him for seven months, with a “mandatory review before the expiry of the order”.

Read the full determination here.

Mr White’s sentencing in December 2016 was described as “shocking” by one lawyer, and led a pharmacist to launch a petition for inadvertent dispensing errors to be decriminalised.

51 Comments
Question: 
What do you make of Mr White's suspension from the register?

M Yang, Community pharmacist

My sympathies to the deceased and family. No one should have to be the victim of a fatal dispensing error but sadly mistakes do happen.

However, I find it strange why only a suspension was handed out. We would all like a world where pharmacists be treated more fairly and not be hastily and disprorportionately criminalised for making errors, but the GPhC should be more consistent. Consider the case of Adam Hamer a few weeks ago. Striking a man off the registrar for mishandling MURs is not proprortional to the act, especially when the individual was suffering from personal problems. I can't wrap my head around why the pharmacist in this case was only handed a suspension.

Farmer Cyst, Community pharmacist

I wasn't familiar with Mr Hamers case, so I just Googled it. Pharmacist struck off for issues surrounding MURs...I'll give you one guess which company he worked for. 

 

Nothing wrong with the culture in that company though. No siree. 

Locum Pharmacist, Locum pharmacist

The requirement for a second check is a running joke in actual pharmacy practice. As a locum I often have to self-check, sometimes for extended periods of time due to organisations taking advantage of SOPs that allow pharmacists to self-check if they take a mental break in between dispensing and checking. This is despite the fact that, after an error, if the pharmacist self-dispensed, they will be blamed for self-checking and not following SOPs.

In this instance it seems the poor pharmacist's employer was perhaps supportive and reasonable following the incident but if this had occurred at a multiple or anywhere else where the employer was less supportive, some long-winded SOP would have been used against the pharmacist to protect the employer from any liability whatsoever despite the working conditions. 

Gerry Diamond, Primary care pharmacist

Oh dear a tragic situation that there but for the Grace of God go anyone pharmacist. I think it would be entirely understandable after this error for him to feel unable to return to practice. The prosecution of a optiican for malpractice was recently over turned and GPs would not be expected to be dragged to court over a prescribing cock up. All I can do is wish Mr Martin well as we don;t look after our own as a profession...

Michael Achiampong, Locum pharmacist

I agree with you Gerry that this dispensing error could have happened to any one of us in the real pharmacy world. That the same two medicines were implicated in the Elizabeth Lee case suggests that sadly, this might not be the last ocurrence. Condolences to the patients' family and relatives. I trust Mr White can access counselling etc. The reality of the drastic DH funding reduction in community pharmacy means that we'll all be self-checking more cautiously than ever before (and even longer prescription waiting times) as supporting staff hours have also been savagely reduced. 

Mike Bereza, Community pharmacist

The name of propranolol should change to something else.

Lucky Ex-Locum, Superintendent Pharmacist

It is quite true that the manufacturers do little to help us out. Just look at Almus products - a lovely looking range it's true, but with a finite colour palette to work with, some packs are bound to look similar (thiamine and nystatin spring to mind). Perhaps plain white packaging with just the name of the product on may work. I'm sure there were less dispensing errors back in the day when everything was in an identical grey pot and the only way to see what you had was to actually read the label....

Hwang Yang Saw, Community pharmacist

Wonder what would be the outcome if similar mistake in accuracy check is done by ACT?

Lucky Ex-Locum, Superintendent Pharmacist

The RP will be at fault, obviously......

Ilove Pharmacy, Non Pharmacist Branch Manager

Have aread(especially younger ones) and ask yourself if it's really worth it for any amount of money never mind £25k

 

Young pharmacist, 25, hanged herself during romantic holiday

http://dailym.ai/2g3AtrK

Amal England, Public Relations

Looks like the link is to the Daily Mail, sorry but I am too intelligent to be going anywhere that trash. Can you summarise the case of the 25yr old.

Lucky Ex-Locum, Superintendent Pharmacist

Assuming a Guardian reader.......?

Also a sorry state of affairs that only one newspaper saw fit to report this. It's an awful case and how many others among us feel that we have the weight of the world on our shoulders? I sincerely hope this is not the first of many.

Ilove Pharmacy, Non Pharmacist Branch Manager

It may well be trash(similar could be said of some pharmacy journals) but some of the stories are not. 

Michael Franks, Community pharmacist

is it just my problem or is it difficult to read yellow figures on a white background ?   

Richard MacLeavy, Non Pharmacist Branch Manager

In the US and Canada I understand all medications has individual product codes that are the same accross different brands. So for example Propanalol 40mg tablets may have a code or PR40T and regardless of brand all packets contain this code which is also printed on the prescription. It then acts as another check and apparently has been very effective at reducing errors. For one thing it stops so many mistakes by inexperianced dispensers dispensing tablets against capsules etc as they have different codes so stops so many near misses and subsequently errors. Why don't we have this? In stead we have manufacturers making different products look as similiar to each other as possible which only adds risk and drives errors in the dispensing process.

Michael Achiampong, Locum pharmacist

Hi Richard - I think you might be referring to the barcodes of individual medicines each with a unique "NDC" identifier number. When I practised pharmacy in the United States in the early 2000s, it was a legal requirement (under Florida Pharmacy State law) for the final checking or "verification" Registered Pharmacist to physically inspect the final product, i.e. dispensed medicine and compare this with a NDC barcode scan of the original medicine against the original prescription(s). Back then, most Rx's were handwritten. So being mindful at that time that North American patients were and (probably) remain the most litigous, I still shudder thinking about the many paediatric Rx's I encountered. They (and CDs) were particularly challenging because they were handwritten so scrawly/illegibly. However, we also had adequate staffing ratios of pharmacists and technicians depending on the peak and trough of the working day; to enable time to contact prescribers and clarify queries. 

Jonny Johal, Pharmacy Area manager/ Operations Manager

This is another case of poor regulation ... should the pharmacist been let off by both the courts or the PSNI Statutory Committee? After all the failures pointed out in this article, from failure to check carefully, failure to implement SOP to failure to counsel the patient! If this case involves a motorist on a charge of "driving without due care and attention", should he be let off if he 'didn't mean to intentionally' driving into a pedestrian, or 'this is the first time' in an otherwise unblemished driving history, or there was 'insufficient time' to implement the highway code, or the pedestrian looked like something else, or 'there was too much pressure' due to too many cars on the road? No, I cannot support decriminalising dispensing errors of any form.

Failure to co-operate with the PSNI investigation should in itself be a striking off offence.

Jonathan Green, Community pharmacist

Maybe if you actually worked at the 'coal face' insted of sitting in your ivory 'corporate' tower you would have more sympathy for this poor pharmacist.

Lucky Ex-Locum, Superintendent Pharmacist

Look at his job title - says it all.

He is obviously a non-pharmacist area manager (I pity the poor sods who work under him) who will never be in this unenviable position because he isn't highly qualified enough to check a prescription.

Darvis O'Rourke, Locum pharmacist

What if you were expected to drive several vehicles at once, and supervise the drivers of other vehicles at the same time.

Jonny Johal, Pharmacy Area manager/ Operations Manager

I thought none of us are obliged to voluntarily drive in dangerous conditions - to continue with the driving analogy. Darvis, poor analogy. In a pharmaceutical sense, I refer to the published obligations re working in unsafe enviroments as issued by the GPhC (sorry, I am not familiar with the PSNI).

Dhanvir Johal, Locum pharmacist

Jonny Johal... you must be perfect

Amal England, Public Relations

Jonny, I totally disagree with you. The info about this case that I have read over the last few months, one can only proportion about 10-20% of the blame on the pharmacist. The rest has to be put on the shoulders of the superintendent of that company. Area Managers often find this hard to accept and would disagree with me. But the concensus among pharmacists on the frontline is that Area Managers/Superintentdents/ Multiples point to SOPs only when situations like these arise. And the other concensus is that the companies are being let off the hook (not the pharmacist).

Jonny Johal, Pharmacy Area manager/ Operations Manager

10 to 20% of the blame, Amal, that is funny. Remember your obligations, if you feel a work environment is unsafe, don’t work and don’t blame others - the title ‘responsible pharmacist’ doesn’t mean your responsibility is limited to ‘10 to 20%’. 

Darvis O'Rourke, Locum pharmacist

You ever tried to close an 'unsafe' pharmacy? and expect to be re-booked. No. I don't think so.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Darvis, this is exactly my point, if you think your professional stance is to choose money over safety, who is responsible for that decision?

Lucky Ex-Locum, Superintendent Pharmacist

Please enlighten us as to what your response would be if one of your pharmacists in your area attempted to close an unsafe pharmacy. That might well make for interesting reading.

Lucky Ex-Locum, Superintendent Pharmacist

We have livings to earn just the same as everyone else. Would you see your family out on the street just for a moral stance?? I doubt it. Your job title says you don't have any morals.

Jonny Johal, Pharmacy Area manager/ Operations Manager

It may surprise you, when I was a part time locum in the old days, I have refused to work in a pharmacy which churned out almost 1600 items a day, with me as the only pharmacist (the 2nd pharmacist who was supposed to back me up was diverted to another store to cover a sickness). I also declined the offer of extra money as well. For your information, I showed a bit of a backbone and I wasn't blackisted by that agency either.

Lucky, your professionalism astounds me. :-) :-)

Lucky Ex-Locum, Superintendent Pharmacist

I've given you a thumbs up for having the balls to answer - respect where it's due. HOWEVER I still totally disagree with your posts. If you have ever made a dispensing error, which you will have (we all do) you are every bit as guilty of a criminal offence as the poor sod in this case. In the eyes of the law, giving someone 100 paracetamol instead of 112 is exactly the same offence as killing someone. Only the outcome is different. Obviously common sense comes to the fore in 'trivial' errors but the fact is that we as pharmacists could be imprisoned for giving someone the wrong number of tablets. That is my argument with you. 

 

 

Pages

Job of the week

Relief Pharmacists
Various locaction in the South West
Competitve + Relocate fee + mileage
Normal datacapture modal