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Xrayser: My recent dispensing error could have been worse

"It could so easily have been propranolol instead of prednisolone – with a career destroyed"

Xrayser wonders where the blame for dispensing errors should fall

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. 


Olukunmi Popoola, Community pharmacist

We need to be more careful. Yes there are work pressures in the pharmacy yet we need to know that we are liable for errors that occur. I gave out fluoxetine 1qds for fluclox 500 1qds a long time ago. fear and worry came on me nothing I've felt before. Luckily the patient was not harmed - even after taking it for one day

Pharmacy HLP, Manager

We are all human and the pharmacist needs good help from the team.

Most errors are made when we insist on helping and jump the queue ( sop ) and help the patient who might be in a hurry.


We are all having to adjust to different environment to handle the cost cutting around us this in itself will lead to errors.


Roy Sinclair, Community pharmacist

Something often ignored in dispensing is the difference between Accountability and Responsibility.  When handing out a pre-packaged prescription to a patient, rgardless of whether a Technician or another Pharmacist assembled it, the pharmacist on duty when the prescription is handed out is the person dispensing it and so is responsible in law.

I have discussed this with pharmacists in the past and some  felt they had little responsibility for any error in an assembling process  that took place while they were not "the rResponsible Pharmacist".

The law would determine accountability but the Pharmacist on duty would legally still be The Responsible Pharmacist.

I agree with all the other comments but worry how spoke and hub dispensing  will ensure appropriate responsibility for any errors can be determined. 

Valentine Trodd, Community pharmacist

The teachers are whinging that they are overworked - now they are looking for a 4 day week. Their petition for such has gotten almost 20,000 signatures! How about we get a petition going for a proper hour long lunch break each day? It's not too much to ask considering a tired pharmacist can and has lead to deadly mistakes in the past. I think the public would be shocked many/most of us don't get a break and would be behind us (as long as they're not kept waiting when they come in to collect their Oilatum at 1.30pm and I have to check it).

Shaun Steren, Pharmaceutical Adviser

One hour (closed) lunch? Come on VT, this isn't France, we are too vulgar and uncivilised for all that. Force a processed sandwich down your mouth and get back to making money for a corporate offshore. It is strange that the French have a productivity levels that put us to shame, but then so does their cuisine. 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

And they are bolshy buggers as well....coincidence? I don't think so. Anything they don't like, it's 'All out lads' and things get sorted. THAT is the model we should be adopting

Valentine Trodd, Community pharmacist

Hear, hear! And if it doesn't get sorted they throw the rattle out and go on strike.

mike harvey, Community pharmacist

i gave penicillamine for penicillin record all my errors and "Thank the Lord"...the stress levels in pharmacy are can we make it a safer place....?   good question for postgraduates  

Valentine Trodd, Community pharmacist

 Penicillamine... dumb name for a drug - didn't they know it would cause confusion? And I know it's a metabolite of penicillin...

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

That's a squeaky bum error!!! I'm guessing they didn't take any?

Valentine Trodd, Community pharmacist

The petition:

61,000 registered pharmacists on the books for 2016 and only 1,759 saw fit to sign the petition. Similarly, a very poor response to the recent online GPhC consultation on workplace pressures/quality in the workplace/whatever it was called - and hardly a mention of MURs. Says a lot about the 'profession' really. If we can't be bothered to help ourselves, how can we expect others to help us?


Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

You know as well as I do why this is, Valentine. I get the feeling you've been around the block for as long as I have and all this workshop nonsense (I AM on there BTW) is just so them up top can say 'We tried' but we all know it'll change nothing.

Valentine Trodd, Community pharmacist

I hope you've up-voted my contribution. I'll give you a hint - it's under 'Other comments on quality' - shouldn't be too hard to spot! And doing quite well too!

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Are you the one with 33 likes? I did up that one (and had a moan at the dozy arse area manager type who commented on it as well.)

Valentine Trodd, Community pharmacist

That's the one. I'm glad they extended the time frame - might make it to the top spot! For all the good it'll do.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Lets us have a chunter I suppose!

Reeyah H, Community pharmacist

Just reading about these things gives me the shivers. We have far too many pressures and now with the cuts, less staff will be there to help the process. Love my job, hate the stress! 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I recently made the worst error I have ever made - amlodipine instead of amitriptyline for someone taking FIVE amitriptyline a night. How the hell they survived completely unscathed apart from a bit of fluid retention is beyond me. It makes my blood run cold thinking about it, but given the pressures and distractions of the job it's inevitable that we make these errors. But what about prescribing errors? I've picked up some humdingers in my time (quite a few potentially fatal ones) and we get no thanks from the GPs for that and I don't doubt that if I'd given it out I'd be in more trouble than the GP.

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