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.