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Xrayser: Here's what goes through your mind after a dispensing error

"You casually look through the prescription bags, trying to conceal your anxiety"

Xrayser argues the sector can’t go another eight years without decriminalisation of dispensing errors

There is nothing like the feeling of seeing a drug arrive in the delivery that you don’t remember checking, but you do remember checking a very similar name or strength. “Hmm – allopurinol,” you think. “I don’t remember checking any of that, but I do remember bagging up some amiodarone…” And as the knot of worry hits your stomach, you rush to the patient medication record (PMR), desperately hoping it’s a coincidence.

Maybe the patient hasn’t picked it up yet, so you casually start to look through the waiting bags, trying to conceal our anxiety from the dispensary staff. Not locating it, you grab the collected scripts and flick through them until inevitably you find the signed and processed prescription.

Fleeting thoughts pass through your mind. “Will the patient notice? Would it be harmful? Can I get away without reporting it?” In the split second these ideas arrive, they are equally rapidly banished, with the realisation that the consequences of trying to conceal an error are worse for both the patient and yourself.

To the PMR then, for patient details and the phone number to call them or, thank God, the summary care record, which now can also give us a patient's phone number. As it rings, we try to compose our introduction. “Mr Smith? It’s Xrayser from the pharmacy. We dispensed a prescription for you and I just need to check…”

The ringing is replaced by a woman’s voice. “Welcome to the messaging service. The person you’re calling is unable to take your call…” and in the few seconds it takes for this greeting to play, you rephrase your message slightly. “Hello Mr Smith, this is Xrayser from the pharmacy. Could I ask you to call me back about a prescription..?” And then you wait. And wait. And try to put it out of your mind to concentrate on the next prescription, and with it the next chance of criminal offence.

We saw MPs pictured having their blood pressure measured at the party political conferences this autumn, but I’m wondering now if decriminalisation of dispensing errors was discussed at these. No doubt there’s an equivalent for MPs of my nightmare scenario, such as a summons to the whip's office regarding a leadership challenge, or a journalist asking about rumours of sexual impropriety. “A momentary lapse of judgement” is often the phrase used by their colleagues, except that unlike our “momentary lapse in concentration”, it doesn’t risk a criminal record.

So I was pleased to read John D’Arcy’s piece about dispensing errors, and horrified to be reminded that it’s now eight years since Elizabeth Lee’s conviction. It’s too easy for the fight against decriminalisation of dispensing errors to be overshadowed by flu vaccinations, impending negative adjustment of this month’s FP34, and repeated crime – such as my pharmacy’s recent ram raids – but surely we can’t also go yet another eight years with this hanging over us?


janet maynard, Community pharmacist

That one issue alone affects me EVERY time I work. all the other issues are secondary


Locum Pharmacist, Locum pharmacist

Excellent article. I had not realised it had been 8 years already what with all the promises of decriminalization being achieved by the end of so-and-so year. Perhaps we are naive to hope the government will take any action to support pharmacists. 

Jonny Johal, Pharmacy Area manager/ Operations Manager

Fortunately the legality of dispensing errors is a matter for parliament and not pharmacists. I have always accepted the legal constraints imposed on me by the law, makes me more careful. 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Ah, Mr Perfect 'never made a mistake' Johal. I've been expecting you.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Come on Lucky, I don't know how long you have been in the business, but do you see the numbers of errors increasing in recent years?

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I've been in this sorry game for precisely 27 years, 4 months and 2 days and , yes the number of errors is going up. This is because of the increase in prescription numbers, the pressures caused by Area Manager/Operations manager bullying over MUR and NMS (yes I am fully aware of your job title), the erosion of the role of pharmacist to little more than a cash cow for multiples, very possibly a decrease in quality of pharmacists because no-one with an ounce of intelligence wants to do this stupid job any more, worry worry and more worry caused by wage reductions , price increases and total lack of job security - how many more reasons do you need?!

Alternative Pharmacist, Community pharmacist

Who told you about me!!! Yes been there done that. The shame of failing perfection is also a major issue for me anyway, the disgrace to my reputation as a 100% caring Professional!

John Cleese, Production & Technical

Yes, that's a great piece, spot on.

N O, Pharmaceutical Adviser

Greeeeatttt post. Nailed it.

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