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‘A momentary lapse of concentration blighted a pharmacist’s career’

"Prosecution is not some theoretical possibility, but an ever-present reality"

The case of Martin White shows why the decriminalisation of dispensing errors can’t come soon enough, says John D’Arcy

I was attracted to a website recently under the banner of “The 10 most well-paid, low-stress jobs”. It featured mathematicians, statisticians, technicians and a number of other job titles ending in “icians”.

However, number nine on the list was pharmacists. Alongside what appeared to be a hurricane-assisted average salary – $121,000 (it was an American site) – was a statement to the effect that this is a straightforward, mechanistic job associated with minimal stress.

Try telling that to the thousands of pharmacists who day in, day out are trying to cope with an ever-growing volume of prescriptions, increasing demands for commissioned and private services, and the 1.6 million patients and customers daily demanding a wide variety of health-related interventions (in large part because the pharmacy is the only readily accessible point of entry to healthcare in an NHS system at breaking point).

In particular, try telling that to Antrim pharmacist Martin White, who in 2014 inadvertently dispensed propranolol instead of prednisolone to a patient who died shortly afterwards. His error resulted in a four-month prison sentence (suspended for two years). And as if this was not enough, he has now been suspended from the register by the Pharmaceutical Society of Northern Ireland. The regulator acknowledged that there was no evidence that Mr White had acted in a “deliberate, reckless or wilful fashion”. Further, it said this was “an isolated incident in an otherwise unblemished career”. In short, a momentary lapse of concentration has blighted a pharmacist’s professional career, possibly to the extent of never practising again.

Patient welfare and safety underpins everything pharmacists do, and making a mistake is every pharmacist’s worst nightmare. As Mr White’s case highlights, the consequences of a dispensing error can be catastrophic; a patient can die as a result, and there could be irreparable damage to one’s professional reputation. It is no surprise therefore that pharmacists pay particularly close attention to this aspect of their role, and it is the principal reason why most pharmacists insist on carrying out a final check on prescriptions. It also results in a very safe system – the number of serious incidents is, thankfully, very rare.

Paradoxically, the error made by Mr White was exactly the same error as made by another pharmacist, Elizabeth Lee, back in 2009, which was also linked to the death of a patient. She too received a custodial sentence (three months suspended), which was quashed on appeal.

Both Mr White's and Ms Lee’s convictions were based on an anachronistic component of the Medicines Act which makes any dispensing error a criminal offence. The offence is one of strict liability and so there is no defence. And as the Lee and White cases demonstrate (and there have been others), prosecution is not some theoretical possibility, but an ever-present reality.

The campaign to decriminalise dispensing errors has been successful to the extent that “decriminalisation” became a workstream of the Department of Health’s “rebalancing medicines legislation” programme board. The board agreed that as pharmacists are only human, there should be a defence available for those who make an inadvertent dispensing error.

A Department of Health consultation on the decriminalisation of dispensing errors was issued at the start of 2015, which received widespread and unqualified support. Since then – at the risk of gross understatement – progress has been slow. Time after time we get assurances that changes to legislation is on the way.  The former pharmacy minister David Mowat said he would be pushing the amended legislation through – he didn’t. More recently, the current pharmacy minister Steve Brine has again hinted that reform is just around the corner. He has also suggested this is a personal priority for him.  

We wait with baited breath to see whether he carries through on this.  

Alongside this, there is now a fresh move to reconfigure the supervision arrangements in community pharmacy. A significant barrier to any debate on this issue – and to any delegation by pharmacists – is the likelihood of being prosecuted in the event of an inadvertent dispensing error. This provides another important reason why the progress on decriminalisation should be introduced as a matter of urgency.

John D'Arcy is managing director of pharmacy support services provider Numark

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Anonymous Anonymous, Information Technology

Less stress in the US due to increased salaries and people actually appreciating what you do! And what is the common denominator between both of those statements I hear you ask?! People paying for their own healthcare instead of the free-for-all buffet lunch that we have of the NHS! The NHS has done pharmacy no favours in their drive to push down costs (and simultaneously quality) of service! Only when patients pay for their actual useage will we be truly appreciated and our salaries reflect the skill required for the job! I know a 26 year old guy that hasn't even been to university that works in the NHS as a band 6 - for a pharmacist to earn band 6 money they must have done 4 years at uni + 1 year pre-reg! What a joke!!!

Locum Pharmacist, Locum pharmacist

It is appalling that these incidents  resulted in suspended prison sentences. In both Elizabeth Lee and Martin White's case, the pharmacists self-dispensed which no doubt contributed towards the error taking place. I believe Elizabeth Lee was working at Tesco's at the time and as we all know, pharmacists working at Tesco's and other organisations continue to self-dispense on a daily basis to this very day. So what exactly have Tesco (or the others) learnt from the incident? Do they not hold any accountability whatsoever for patient safety?

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Tesco written policy is to have a pharmacist and dispenser on duty at all time. Their unwritten policy is to have a pharmacist alone until 8am and after 8pm. OK so these are very quiet periods in the vast majority of branches but how they get away with this contradiction is beyond me.

Locum Pharmacist, Locum pharmacist

Must say, it really annoys me when staff say 'it's quiet, it will be fine'. If you are serving customers, answering the phone, dealing with unusual queries and self-checking all by yourself, it is not quiet. Unfortunately though, the current scenario in pharmacy is one where it is okay if you don't have staff as long as you have all your paperwork in order (SOPs, Clinical Governance, etc).  

Peter Marshall, Community pharmacist

John D'Arcy raises a very important issue in that a pharmacist has to ensure he is working in a safe environment. Every pharmacist can potentially make a mistake,we are only human after all. The biggest barrier to safe practice is dangerously low staffing levels. If you are a locum and arrive at a pharmacy where the staffing levelsare unsafe the best option is to close the pharmacy. Perhaps as a profession we need to be brave, and tell penny pinching employers that it is not acceptable to work in dispensaries where it is obvious we cannot operate within standard operating procedures due to the chronic low levels of support staff.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Trouble with this is the same old story - pharmacists have never and will never form a united front. If we threatened to go on strike the employers know full well that there will be enough locums who will still work to make a strike totally worthless (and I have sympathy with those locums because they have a living to make and bills to pay the same as the rest of us)

Caroline Jones, Community pharmacist

I suppose, Jonny, it comes down to the process applied to other health care professionals.....whatever these processes are, they should be equal; so if Drs, Nurses and Dentists etc are afforded the 'luxury' of not having 'strict liability' applied to inadvertent errors then so should Pharmacists?

Jonny Johal, Pharmacy Area manager/ Operations Manager

To be honest, I don't think professional equality applies, especially when it comes to pay. I do support criminalising medical negligence. I have been on the register for 37 or 38 years and criminality for dispensing errors never bothered me, nor did I feel stressed as Mr D’Arcy suggested. 

For those pharmacists who worry about the criminality element of the job, I do sympathise, but we all joined the profession in full knowledge of this. If someone is stressed enough to making enough errors to be worried about being sent to jail, my thought is someone should review whether the job is right for one.

MA WILLIS, Locum pharmacist

This is the type of silly comment that I would expect from a Pharmacy Area Manager. Maybe you don't feel stressed because you maintain low staffing levels in pharmacies you visit without working in, whilsts constantly stressing pharmacist out over targets such as how many MUR's have they done?I can probably guess which company you work for too.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Jonny - I've been in this lousy game for 28 years and it's changed unrecognisably since then. The pressure has become intolerable for a lot of us (look at the case of the poor girl who killed herself recently) and it's mostly down to all of the extra work we are expected to do. MUR, NMS and flu vaccines have become the cash cow for employers so they push those to the detriment of the rest of the business, while hanging the pharmacists out to dry in the event of an error. Just remember - one single solitary error is enough to land you with a jail term so your final sentence makes no sense.

Just a thought - if a GP had prescribed propranolol instead of prednisolone, would they get criminalised for it? Of course not because a PRESCRIBING error is NOT a criminal offense.

Ilove Pharmacy, Non Pharmacist Branch Manager

You're right Johnny, though all earn more than a typical pharmacist(yes even the lorry driver who does not waste 4/5 years on a degree course). The question is risk vs reward!? And community pharmacy is probably not worth the risk.

stanley steadman, Hospital pharmacist

Any other professional will only be prosecuted if it can be proved that they were negligent.Any dispensing mistake made by a Pharmacist is in the eyes of the law an automatic criminal offence and there is no defence that can be offered this is unjust!

Jonny Johal, Pharmacy Area manager/ Operations Manager

Stanley, you have opened a can of worms if you want to discuss negligence. Maybe someone from the PDA can help, how successful are they when they try to prove in court that an error had occurred but not due to negligence? or do they usually settle out of court in such cases?

Jonny Johal, Pharmacy Area manager/ Operations Manager

I wish to point out to Mr D'Arcy that 'momentary lapses of concentration' do blight many people's careers, pharmacists are not on their own, the same can be said for airline pilots, lorry drivers, doctors, lawyers etc ...

I wonder what advice he would give to a fighter pilot who finds flying a fighter jet, monitoring the radar, communicating with air traffic control, aiming at your enemy, firing weapons and navigating too stressful?

Taking note of the title of this article, does Mr D'Arcy think killing a patient should not blight a pharmacist's career?

Mark Boland, Pharmaceutical Adviser

Mr Johal, I think you need to work on your reasoning skills, your analogies are appalling. When a surgeon operates on any patient, the success rate of that operation includes an element of human error. It is deemed absolutely acceptable for a surgeon to accidently damage a vessel or nerve in any given operation, however serious the consequence (often death). The surgeons performance is compared to other surgeons (who will also make mistakes). If you could be bothered to read any of the recent autobiographries by many eminent surgeons (which I imagine you couldnt), you would see how they describe having 'bad days'. Often patients will present with the need for near indentical surgeries, and with very similar risk profiles the same surgeon has a success in one operation and a death in the other. The surgeon describes a lapse of concentration and catastrophic damage to a blood vessel. This does not blight that surgeons career. This error will always happen when a human is involved and so an accetpable error rate is established from which humans can be judged. Do you get it now?

Jonny Johal, Pharmacy Area manager/ Operations Manager

Mark, have you seen those web sites that log US doctors' litigation histories ... if you think mistakes or bad results do not have an impact on their career, you are very mistaken. For your information, I have a brother, originally trained as a general surgeon, who worked in Canada until he retired a few years ago. He would disagree with your assessment, and your perception of his mentality (as far as I am aware, he never had a negligence suit either). If you want to defend pharmacists right to make mistakes, you are in the wrong profession, and if you think killing a patient should not blight one's career and that pharmacist should carry on dispensing happily, then I suggest you seek psychiatric help.

Mark, have some pride in what you do, don't accept errors as 'just being human', do something to stop errors happening, be switched on, the GPhC does have some good advice on their web site for us on this subject.

Mark Boland, Pharmaceutical Adviser

So you think the litigious culture of the United Stated should decide what ought to be the case in this country? Anyway, as ridiculous as your comparison is, we are discussing what happens in the NHS and so you make a moot point.

All pharmacists make dispensing errors, it involves a high degree of chance whether your mistake causes a death or not. I accept errors within the context of this fact. The aim should always be zero error, but as this will never be possible, minimising errors to as low a rate that is reasonably possible, becomes the order of the day.

As with regards needing 'psychiatric help' and your 'brother' being a 'surgeon' (how convenient for your post), I think you need to consider how your very poor grammar, repetitive diction, grandiose claims and very poorly reasoned posts reflect on your own professionalism.

Jonny Johal, Pharmacy Area manager/ Operations Manager

For a reasoned debate, please concentrate on the subject and keep irrelevant personalities out. 

Mark Boland, Pharmaceutical Adviser

‘keep irrelevant personalities out’ ? May I have this in grammatically correct English please?

R S, Community pharmacist

Are you a pharmacist Jonny?

Jonny Johal, Pharmacy Area manager/ Operations Manager

On the register for 37/38 years. 

Dave Downham, Manager

Does that mean you dispense 27/28 tablets at a time?

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

If I was coming up to retirement, I'd be as blase about this as Mr Johal. 

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