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NPA sees rise in indemnity claims related to MDS errors

NPA: The right process may not always have been followed when handing trays to patients
NPA: The right process may not always have been followed when handing trays to patients

The NPA has seen an increase in the number of indemnity claims relating to the preparation and dispensing of monitored dosage systems (MDS), it has told C+D.

National Pharmacy Association (NPA) director of pharmacy Leyla Hannbeck used her latest update to superintendents to flag the common dispensing errors that have resulted in “significant indemnity claims against pharmacies”.

Redispensing of patient-returned medicines (see below) and look-alike, sound-alike errors feature in the update, and “MDS claims have definitely been on the rise”, Ms Hannbeck told C+D on Tuesday (July 16), contributing to “a number of claims” submitted to the NPA.

The NPA declined to confirm over what period it had seen this rise, or how much the claims amount to, due to the sensitive nature of the cases.

Prepared MDS trays

On two occasions flagged in the update, MDS trays prepared with antidiabetic medicines were dispensed to patients without diabetes.

In one incident, the patient’s solicitors alleged the patient took the medicines from the incorrect MDS tray and collapsed, before being found by a carer. The patient was admitted to hospital and the solicitors allege the patient has been left with a significant cognitive brain injury.

In the other incident, a tray of antidiabetic medicines was allegedly dispensed to the wrong patient. Following a prolonged period of serious illness in hospital, the patient died, Ms Hannbeck said in her update.

“Despite questions over causation issues, this has resulted in a claim against the pharmacy.”

These claims “may have arisen because the MDS trays had been prepared in advance, stored in a stack on the shelf, and potentially proper processes not followed at the time of handing it over to the patient”, Ms Hannbeck suggested.

In another example of an MDS error, a patient was administered medicines from the wrong tray by a care company, she said.

However, the care company is also asserting that the pharmacy supplied them with the wrong MDS tray, which resulted in the error. The company is seeking to recover its outlay to the patient, she explained.

These companies “have a duty of care and must be able to demonstrate accountability to ensure they have the right training and processes in place for their staff for managing medicines in care settings and administering them to patients”.

Other common claims

Another example of a common dispensing error resulted in a “significant claim” against a pharmacy, after patient-returned vials of heparin were accidentally redispensed to a pregnant patient, Ms Hannbeck outlined.

While the patient was then treated with preventive medication against the potential risk of infections and went on to give birth to a healthy baby, the experience allegedly resulted in a “significant ongoing psychological impact”.

Ms Hannbeck advised that all waste medicines and patient-returned or expired pharmacy stock should be properly segregated and that all pharmacy team members implement their pharmacy's patient-returned medicines standard operating procedure.

She used the latest update to also highlight the most common look-alike, sound-alike errors that result in claims against pharmacies: a confusion between amlodipine and amitriptyline, and between risperidone and ropinirole.

She also stressed the importance of thorough record-keeping in the pharmacy.

Read Ms Hannbeck’s latest update in full.

Does your pharmacy regularly dispense MDS trays?

Ranjeev Patel, Non Pharmacist Branch Manager

Hang on a minute. Patients are being harmed here and being put at further risk if this continues. The GPhC is mandated to only protect the public as they enjoying spouting when you ask them for anything. So what are they doing about this? Nothing? What a surprise.

We’re all doomed, Locum pharmacist

Prompting is now administration support and thus needs a MAR chart. A MAR chart used for original packs is not fit for purpose for MDS. 

The guidance to deliver a 6R check therefore needs to be undertaken, difficult when the bubble contains 22 entities including a big Adcal tablet. I too refused to check sealed trays. 

The guidance for social care clearly states we should supply in OPs see 1.9.7. unless we have assessed. 

And this is the fundamental issue as a profession we don’t all commit to deliver on this message. 

If all the trays supplied how many pharmacies actually know which are for the individual and which are used by carers?

Fragmented, disjointed, easily exploited that’s what we are!

We’re all doomed, Locum pharmacist

Social care providers should be following 

Managing medicines for adults receiving social care in the community

NICE guideline [NG67] Published date: March 2017. 

How many pharmacists are aware of this document? I clearly recall the debate with social care providers that MDS is for a client not the carer. If one is required I will make that decision. The response ‘well if not your prepared to do it or going to charge I’ll go to Footwear pharmacy they’ll do it for free’


Chris Locum, Locum pharmacist

Unfortunately, paying lip-service to safety with overworked people and understaffed premises has expensive consequences. The Government doesn't pay the bill. The pharmacy does. Big companies offering to provide professional services for nothing has brought us to this juncture.

Mark Boland, Pharmaceutical Adviser

Boots started 'free' MDS. Under the more generous prescription payment system of decades past, a profit could be made. As with everything in community pharmacy, per unit payments fell but the number of units of work increased. The chains maintained the profit margin by making the staff absorb the cost: more MDS - no extra staff.

The government have decided that this slave work force is now too expensive for their tastes. Off-site robotics and pharmacy closures is the only acceptable cost to them.

Cod Fillet, Community pharmacist

Pharmacies operate at money loss with MDS and risk all this errors and claims!!

The answer is to charge £10 per tray (saw this a few weeks ago in an independent pharmacy) or only do if seven days Rxs. This would be the easiest ever issue to tackle. Even easier than charging for deliveries.

Problems occur when someone down the road rides in and offers to do everything for nothing. Around 18 months ago one surgery stopped 7 day prescriptions for care homes (I have no issue with this), making it economically impossible for us to provide MDS. We informed the care home and around 2 weeks later Boots agreed to take over and still provide MDS. It is a 60 bed care home we estimate would now produce 450-500 items every 4 weeks with 28 day scripts.

Farmer Cyst, Community pharmacist

More fool them - if you genuinely were going to be losing money dispensing those scripts overall (which I think many independents would) then you WANT those patients to go elsewhere.


We haven't been taking on any new MDS patients for the past year if we can help it, and certainly not without 7-day scripts. Sometimes the patient gets told about Boots and their wonderful ability to put whatever you want in a pack!

Joan Richardson, Locum pharmacist

No surprises with this - staff shortages result in rushed preparation of MDS.  Lack of communication when patients' meds are changed either by the GP or following a hospital stay.

I have worked in several pharmacies where the trays are sealed before checking - trying to peer into a packed compartment to work out what is actually in there is well nigh impossible.  Requesting that the MDS is unsealed  and then sealed again does not make you popular but it is the only thing to do.

Interleukin -2, Community pharmacist

Not to mention you'd be labelled "awkward" and your bookings are instantly at risk as they ll fill a very toxic feedback report to rota coordinator requesting cancellation of all future bookings

Adam Hall, Community pharmacist

1. Don't provide MDS without an assessment

2. Don't provide MDS for use by carers

3. Follow the process

I know it's easy to say these things but, fundamentally, that's what needs to happen. Patients may be upset; Carers may be upset but I see no benefit in additional workload just because "My doctor says I should have it" - Fine, let the doctor pay for it!

Joan Richardson, Locum pharmacist

Would be nice not to suply MDS for use by carers but we constantly get "carers won't prompt patients to take meds unless they are in MDS".  The pharmacy is constantly caught between the proverbial rock and hard place.

Farmer Cyst, Community pharmacist

"carers won't prompt patients to take meds unless they are in MDS"


So what? Not your problem - don't take on significant financial burden and legal risk because of a shitty care agency. They shift all of their cost-cutting on to you, and if anything goes wrong do you think the 'care staff' are going to do the right thing and admit their fault?

Adam Hall, Community pharmacist

All you have to do is say that MDS is not designed for use by carers. If care service providers then decide not to support patients with their meds, that is up to them. Not my problem. Alternatively - "Yes, I will provide MDS for your care agency to support at a cost of £x per tray" 

Reeyah H, Community pharmacist

These claims should be passed on to NHSE. It’s chaos in community pharmacies with lack of staff - the cutbacks by the government are showing the effects. 

N patel , Non Pharmacist Branch Manager

simples... charge where possible for preparing mds trays.. most patients will transfer to pharmacies that dont charge... less stress less hassle less time wasted less losing monies.....

V K P, Community pharmacist

another good way of making money for the NPA Leyla! recording referral advice and emergency supply refusal can be done by ordering the Pharmacy referral and record keeping book, contact NPA Representing You on 0330 12300190. do these come for free?? Not in a million years.

Record all referral advice, unpaid work once again.  All these can be addressed by seeing patients that require pharmaceutical advice and only have those come to us. the rest can go to the GP. let the GPs give out the free advice and keep records for it. GPs get a fee for referrals as part of their GMS. so where is the pharmacy equivalent NPA???? 

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