About 10 minutes after I had dispensed his prescription for sertraline 50mg, the patient walked back into the pharmacy. “I'm supposed to have 28 tablets, but there's only four in this box…”
You can probably guess what happened. I apologised for having dispensed a box of 50mg sildenafil, thanked him for bringing this to my attention, and explained the fault analysis process.
On this occasion, the process consisted of me cursing the stupidity of my mental lapse. With one dispenser on holiday and the other at lunch, I had omitted the mental break required to prevent a miss-pick, partly because my mind had been on a quality payments criteria I was working through. As if on auto-pilot, my hands had picked and labelled the wrong tablets. It could so easily have been propranolol for prednisolone – with a life lost and a career destroyed.
"The road to hell is paved with good intentions" – that could almost be a motto for our profession. Whether it's reviewing a patient's medication without a certificate, accessing their summary care record (SCR) without explicit permission, or dispensing medication under the difficult and stressful conditions of our still unaddressed workplace pressures. And still the slightest breach of the Medicines Act is a criminal offence.
Of course it’s right that pharmacies do everything to address the possibility of harm arising from our dispensing and other clinical services, and it’s right that General Pharmaceutical Council inspections are focussed upon this risk reduction. That the whole working environment be organised to prevent harm is the principle by which the Health and Safety Executive operate.
Since 2007, companies and organisations can be found guilty of corporate manslaughter as a result of management failures resulting in a gross breach of a duty of care. But what would that mean in the setting of a pharmacy? Who is ultimately responsible for our working environment?
Yes, it’s true that "to err is human", but there are certain occupations and professions where human error is hard to accept, the so-called 'never events'. This is the NHS term for serious incidents that are wholly preventable, as guidance or safety recommendations providing strong systemic protective barriers should have been implemented by all healthcare providers. Dispensing propranolol instead of prednisolone should be a 'never event'.
I applaud the petition started recently to highlight again the disparity in the legal situation surrounding dispensing errors, but we must be careful not to appear to lose sight of the tragedy for the patient or their relatives. As well as stopping pharmacists being criminalised for being human, we need to deflect blame away from the pharmacist alone and onto the workplace pressures which may be managerial, institutional, or contractual.