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Do you remember your first dispensing error?

Martin White was sentenced last month to four months in prison suspended for two years, for dispensing propranolol instead of prednisolone in the hours leading up to a patient's death in 2014

NHS pharmacist Pam Adams revisits her own past to explain why she launched a petition in response to the sentencing of Martin White.

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, 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.

What do you think about the sentencing of Martin White?

Leon The Apothecary, Student

My opinion is that the first step to reducing errors across the board is to minimize the amount of human interaction that occurs with the medicine products. I suspect automation and the use of robotic technology would go far in reducing errors.

Jupo Patel, Production & Technical

Why would any of you pharmacists admit to errors when you can be prosecuted??? Still a blameless culture in the NHS or is that just lip service.

Robin Conibere, Primary care pharmacist

Well done Pam, I remember my first, Zopiclone 7.5mg instead of 3.75mg. Fortunately no harm came to the patient, which is the most important thing, and the second most important thing is that I learnt from it, as did I from other dispensing errors I made. The previous comments highlight the fear of being open and honest about these errors due to the risk of prosecution and the legislation needs to change ASAP. I would encourage Pharmacists (and policymakers) to read Matthew Syeds book "Black Box thinking" as its an excellent examination of the examination of failure to improve and be succesful in many different areas. CD & Pam we need a good Hashtag to keep raising the profile of this on SoMe and eventually, something may be done

Valentine Trodd, Community pharmacist

"Fortunately no harm came to the patient..."

What possible harm could ever result from 7.5mg zopiclone? Maybe a little higher than the patient is used to, but within the therapeutic range. I'm not saying we should be complacent regarding dispensing errors, but a certain small percentage should be acceptable - as they are an inevitable part of the dispensing process. I have seen a pharmacist call both a patient and urgently request to speak the patient's GP because they accidentally dispensed a non-sugar free formulation rather than the SF one prescribed - judging from the PMR the patient was NOT even diabetic! Needless to say the GP wasn't impressed. Likewise I've had a locum needlessly panic an elderly patient because they were given simvastatin 20mg instead of 10mg - and they'd taken one!!! The locum had advised her to contact the GP - she thought she was in mortal danger. All I'm saying is we need to apply a little common sense to the situation...

Ben Merriman, Community pharmacist

Even in 2017, a dispensing error in the UK remains a criminal offence.  Given that, anyone replying to your question and giving details of their first error in theory risks investigation, I suspect numbers of comments on this page may be on the low side.  Myself?  I'm going to follow suit and make use of the Fifth Amendment...

Valentine Trodd, Community pharmacist

Go on you rascal, I bet you never made a mistake!

Ben Merriman, Community pharmacist

I did once made a cup of tea with sugar instead of sweetener

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Potentially fatal error if it's for a dispenser on a diet....

Valentine Trodd, Community pharmacist

Shhh, don't let the GPhC hear about it...

Gerry Diamond, Primary care pharmacist

Another area of risk for pharmacists in emerging roles in terms of prescribing, OOH advice, and practice pharmacists comes from the woeful social services, care-nursing homes and supported living sectors. Most carers and support workers are poorly paid , low skilled and inadequately educated phonining up asking for the pharmacist to give authorisation for missed doses, covert administration and last minute medication training. My advice is give nothining in writing, record your discussions, names of carers and advise them please go back and review your medicines administration care plan and policies if you are making any changes. That is their responsibility as an organisation or contact with their client. Don't carry the can because social care services are so poorly financed that you need to take on their burden of care planner and scape goat.

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