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Decriminalising dispensing errors is still a fantasy

"When the patient hits the floor the blame travels in the direction of the responsible pharmacist"

We are yet to escape the threat of prosecution through our supply function, says Xrayser

I don’t know how your university course started, but on day one of my pharmacy degree we were handed round a series of newspaper cuttings that reported deaths attributable to dispensing errors. This would be like welcoming medical students to their calling not with an image of Hippocrates, but Crippen, Mengele and Shipman. I was reminded of this as I read David Reissner’s blog in C+D last week.

This foremost pharmacy law specialist warned that it’s only a matter of time before we’re charged with manslaughter as a result of a prescribing error we didn’t identify by using the patient’s summary care record (SCR). “Not checking may be negligent if clinical judgement means SCR should be accessed,” he told me on Twitter. So to the infamous legal cases involving 100mg morphine and concentrated peppermint water, we may soon add “the unchecked penicillin allergy”.

Reading David’s article about our medico-legal accountability, I was put in mind of a phrase but unable to identify its origin without my favourite post-graduate tutor, Google.  The phrase is, “With great power comes great responsibility” and it comes from the closing lines of the first Spiderman story in the 1962 comic “Amazing Fantasy”.

It is just as true when applied to the dichotomy between our clinical services and dispensing. We are forever being encouraged – forced some might say – into moving away from just handing over pills, to take responsibility for ever more complex clinical roles. Yet it seems we cannot escape the consequences of harm resulting from the supply aspect of our role.

It may be no excuse that an experienced and highly qualified doctor with access to the patient’s full care record – not just a summary – unwittingly prescribes an antibiotic to which the patient has a serious allergy. Nor does it matter if that box of penicillin is dispensed via an off-site “hub and spoke” supply system, or if the final check is completed by an accuracy checking technician. When the patient hits the floor, the blame travels in the direction of the responsible pharmacist.

Reading more about legal action against a responsible pharmacist also suggests as great responsibility does not come with great power. It just comes with trying to do a good job in ever more stressful situations. This stress is only enhanced by a £2,000 drop in dispensing income for the coming two months alone, which for many pharmacies equates to 150-250 hours of dispensary staffing.

And despite seven years of campaigning and two changes of government since Elizabeth Lee was handed a suspended prison sentence for a dispensing error, these remain a criminal, rather than a professional, matter. If we find a way to address this in my lifetime, that really will be an Amazing Fantasy story.


janet maynard, Community pharmacist

Just makes me want to retire asap!


M Yang, Community pharmacist

Personally, I prefer the X-Men! Still, I appreciate the reference to the web slinger. In the meantime, I suggest all pharmacists maintain a record of anything out of the ordinary in the workplace. Any significant events, or something your gut tells you might have repercussions (even if it is just an unpleasant conversation/altercation with a patient). I had a patient who disagreed with the doctor's prescribing decision but at the same time wasn't going to leave until I gave him something to take away. It left me in a very difficult position which was only resolved after several back and forth phone calls. I kept a very detailed record of this event and promptly notified the PDA after work. 6 months later and nothing's come of it, but I felt safer anyway. I knew doctors have much greater protection in the event of a prescribing error. When you have the formidable BMA backing you up, you tend to become complacent and probably wouldn't keep written journals of such things.

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