Dispensing Errors

Question 1

What errors can occur when dispensing?

Answer 1

• Picking error
  ¬> Dispensing a different medicine
  ¬> Dispensing the correct ingredient but the wrong strength or form
• Counting error
  ¬> Dispensing the correct medicine but the wrong quantity
• Labelling error
  ¬> E.g. incorrect dose, patient name, incorrect drug name, drug strength
  ¬> Dispensing a medicine that has expired
• Handout error
  ¬> Giving the medicine to the wrong patient

Question 2

What could happen if a pharmacist makes an error?

Answer 2

1. Making a dispensing error is a criminal offence and prosecution may follow (NB the law has been changed to allow for a legal defence but it is still a criminal offence).
2. The patient may sue for damages and claim the pharmacist was negligent.
3. The General Pharmaceutical Council may investigate the case (as a Fitness to Practise issue).

Question 3

How could the pharmacist learn from errors?

Answer 3

• Pharmacists should keep records of: near misses (Prevented Errors), dispensing errors (Unprevented Errors).
• Meetings should be held regularly to review these records.
• It is important that there is a ‘no blame culture’ and that people are open and honest in recording errors and discussing them.

Question 4

What does the ‘duty of candour’ mean for healthcare professionals?

Answer 4

• Tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong.
• Apologise to the patient.
• Offer an appropriate remedy or support to put matters right (if
  possible).
• Explain fully to the patient the short- and long-term effects of what has happened.