Do you remember your first dispensing error?

I was a newly qualified pharmacist working in a small district general hospital – one of three “basic grades” working a rotation. My boss called me in to explain that one of the consultant paediatricians had found a dispensing error.

I had given a baby Sando-K instead of Sandocal. The tubes looked almost identical. I felt sick, dizzy and terrified. How was the baby? The consultant and my boss were sympathetic – the baby had only taken a few tablets and it was all going to be OK. They supported me through this and there were no lasting consequences.

The sentencing of Martin White

Which leads me to Martin White. I first heard about Martin White of Belfast Road, Muckamore in County Antrim, on a WhatsApp feed from colleagues working in GP surgeries. I immediately looked up the case on a news website. Seeing Martin’s face and hearing his story had a profound effect.

An apparently hard-working, tired, stressed human being with 25 years of good clinical practice behind him had been dragged through the court system. My sympathy obviously went out to the family of the victim who died as a result of this tragic mistake. Martin hadn’t meant her any harm. He hadn’t been reckless, yet will carry that burden of guilt forever.

Would he ever be able to work as a pharmacist again? Would he be able to show his face in the local community he had so diligently served? Might his “low mood” [according to news reports] turn to depression, as he faces the uncertain future as a “criminal” awaiting sentencing?

Where were the professional leaders in all this? Didn’t we already have an assurance that such inadvertent dispensing errors would be decriminalised?

Having worked in hospitals, I have observed countless errors made in clinical practice. Thankfully, most caused no harm, or at least only minor consequences. Even serious errors were investigated by a “no blame”, or more latterly a “fair blame”, model.

Staff involved were supported and encouraged to report and learn from mistakes – to be open and honest, with the expectation that true “human error” would not result in criminal sanctions for the individual. We received “human factors” training, which looks for the behaviours and pressures which can lead to mistakes.

I used one of these NHS training slides as a header for my petition. Despite all the science and research modelling, there still exists a box on the slide labelled “human error”. We can’t eliminate all mistakes, so why prosecute and criminalise those who, despite taking all reasonable measures, still err.

Taking a stand

I have often signed petitions on change.org, but this was my first attempt at starting one. It took a while to organise, for a social media dinosaur like myself.

Surely the profession of pharmacy would stand and be counted when a colleague had been criminalised for a mistake we could all have made? My contacts in pharmacy did not disappoint me, and I soon had 50, then 100, and now over 1,000 signatures – not all of them pharmacists.

C+D has publicised and supported this case and similar ones over the years. We need such champions when our appointed professional leaders are slow to act on our behalf. Let’s get others to sign the petition and show Martin that his colleagues support him. Let’s tell those in authority that the Medicines Act of 1968 desperately needs to be updated. 

The punishment of knowing you have caused harm to a patient is more than enough, and the threat of imprisonment is cruel and inconsistent with our NHS culture of openness and learning from mistakes.

Pharmacists who make genuine mistakes and own up to them are not criminals.

Pam Adams is an NHS pharmacist in Gloucestershire. You can sign her petition here.