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Pharmacists turn blind eye to colleagues’ dispensing errors

Practice More than a third of pharmacists responding to a C+D poll said they were worried that reporting an error would affect their working relationships, sparking fresh calls to decriminalise dispensing errors.

More than a third of pharmacists do not report colleagues' dispensing errors for fear of damaging relationships, a C+D poll has suggested.

Two thirds of readers were worried about the potential effect of reprting colleagues'  dispensing errors on their working relationships. And 59 per cent of these (38 per cent of the total respondents) didn't report errors as a result. Thirty six per cent of the 112 readers polled said they had no concerns over the effect of reporting dispensing on working relationships.

About a quarter of respondents said they continued to report errors despite their concerns.

The results prompted fresh calls to decriminalise dispensing errors, as pharmacy leaders said the law was discouraging pharmacists from reporting mistakes.

The law needs changing to encourage open reporting of dispensing errors, industry leaders said

More on dispensing errors

APPG to discuss dispensing error laws with       govenment

Pharmacists make four dispensing errors a year

Patient safety will be priority in dispensing error laws

The threat of criminal prosecution made it "hardly surprising" pharmacists were reluctant to report errors, said Numark's director of pharmacy services Mimi Lau. "If a culture of external reporting is to be encouraged, then the law needs to be changed immediately," she argued.

"We need to remove the criminalisation of genuine errors," agreed IPF chief executive Claire Ward. "This will encourage better reporting, learning from mistakes and, above all, improved patient care and safety."

Some employees also faced dismissal for making a single error, the Pharmacists' Defence Association (PDA) told C+D. Technically, a dispensing error was a breach of a standard operating procedure (SOP), it said.

"Not every employer will dismiss pharmacists for breaching a SOP, but many will use it as an excuse for dismissal if they have an agenda to do so," PDA director John Murphy said. This led to employees being wary of alerting managers to their mistakes, he argued.

The Royal Pharmaceutical Society (RPS) encouraged pharmacists to report dispensing errors anonymously through the NHS's National Patient Safety Agency if they were afraid of damaging relationships.

"This also helps employees to consider the environment and gives them agency to enable a just culture where incidents and errors are reported," said RPS spokesperson Neal Patel.

In December, the all-party pharmacy group called a meeting with the government to discuss the decriminalisation of dispensing errors, arguing that it had been a problem for "far too long".

Could you justify turning a blind eye to a colleague's error?

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Chris Locum, Locum pharmacist

If we had a truly anonymous system of reporting to a national database coded with various types of error, the true picture of activity in dispensing would be laid bare. As would the consequences of remote supervision.

Until we do the stack it high and dispense it it 3 microseconds while vaccinating and doing NMS, MUR (and figuring out whether you are using real product, rather than pirated brick dust) presents little opportunity for change.

It is not a blame free report this to 'lets all learn from this '@ benign
We all know that is rubbish.

David Liston, Other pharmacist

If we want to reduce the incidence of dispensing errors then we need to know the level of errors and the factors that influence the making of errors.
I recently spent a lot of my own time looking into "psychological factors" pertaining to error production (medical errors are merely errors occurring in a medical context) and produced an article entitled "there's many a slip ........" and sent a truncated version to Chris Chapman who after some considerable time and faffing around informed me that they were not interested in using it! We are often accused of being apathetic but the truth is we have always been encouraged to be apathetic by the pathetic attitudes of those in a position to influence change but who too frequently are influenced by other interests! Dave

Chris Locum, Locum pharmacist

Have you shared the details in another forum David? I think in another previous post you said there had been a less than interested response from those who could take notice !

This is just so important and yet its not getting the traction it needs. Just strike off John or Jane Pharmacist cos they don't cut the mustard, and replace them with the surplus bodies around. Great attitude...not

David Liston, Other pharmacist

Hi Chris, has something been redacted from your post or is that a natural large space in the middle?
My intention is to post a full copy to the GPhC in attempt to open their minds to the possibility that someone who has had a very varied career spanning 40 years in community pharmacy may just have some idea about its strengths and weaknesses and if they choose to disregard it then at least I have made a positive effort! Best wishes,Dave.

David Liston, Other pharmacist

The most important thing is to detect errors and then resolve them. Errors are part of nature and apparently if DNA did not regularly make errors we would not exist in our current form. I think most pharmacists have the correct attitude towards errors and the problem is with the "Others".

Leon The Apothecary, Student

It'd be weird to see a dispenser in a prison for accidently mixing up trimodine and trimovate next to a person who'd assualted someone. Mistakes will happen, it's human nature. That's why CPD's exist - to learn from mistakes and to make sure that they don't happen again. Criminalisation stops this process, it doesn't allow a learning progress. Rather, it causes fear to the profession meaning these potentials to go answered.

Gerry Diamond, Primary care pharmacist

Clearly the decriminalisation needs to happen, and the premise of how it is done in law is quite convoluted and applies to manufacturing rather than dispensing. That said, it is important to report matters just in case they get taken further, learn from mistakes, improve processes, reduce risk and make the patient safe. I don't envy pharmacists in high volume dispensing operations, few proper breaks and setting people up for a fall are all dirty tricks that do happen. We should be talking about how to support one another and not trash colleagues as most pharmacists put themselves through the mill psychologically when there is an error.

Pavol Kosa, Locum pharmacist

Agree. Decriminalisation of dispensing errors should be done and probably the ones unintentionally done.
There is enough pressure to do 'enough' MUR's and NMS's during shift except from securing safe and effective dispensing of medication and managing team as we are legally responsible for it. Co-operation is important , but on the other hand I believe some stronger disciplinary procedures should be in place if there is not ' enough respect shown' towards responsible pharmacist by members of staff, from my example some do not know what WWHAM means and are unable to ask and get enough info from patient for pharmacist to make sensible decision.

Pavol Kosa, Locum pharmacist

Disciplinary should be done to those who think about money/bonuses first , then patient. I believe it should be patient first, then numbers. We are human beings and I like doying them and speaking with patient, but some branches are behind two or three days with prescriptions, so sometimes there is not enough support staff and line managers do not care. Well it should be about co-operation and as for travelling I believe when locum is changed within short notice, e.g less than 48 hours except from milleage should be paid extra travel time as for difference between branch we should travel and the one they changed us to, because time is money. In nowadays times where more pharmacists are finishing there should be two pharmacists on premises, one who will cover cost by completing enhanced services and the other for the rest. So one MUR is £28 pounds, so let's say in 9 hours shift with reduced rates it would be easy to do 7-10 Mur's and everybody would be happy. In busy branch with not enough trained staff is not problem to do 2-3, I get used to do 15 easily as double cover, but it should be working both ways, not only bonuses from it, health and safety of patients is the same important as health and safety of pharmacists on premises I believe.

Pavol Kosa, Locum pharmacist

Pushing responsible pharmacist out of computer like it happened to my friend and me and telling him he is a little s..t is not acceptable and such person should not be promoted but disciplined and probably sacked. Forcing pharmacist by telling them that if they will not do so many MUr's will be not booked and like in my case I have to do 3rd one after I have done two and dispenser refused to help, when HCA needed help with serving and nothing had happened, so it is very bad situation for securing safe and effective environment to work for both pharmacists and patients health and safety.

Stephen Evans, Work for a pharmaceutical company

Ok so firstly this is a very subjective question and secondly I'm not sure that a poll of 66 people counts for much at all.

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