Wk 26 Dispensing Errors PDF

WEEK 26 Dispensing Errors Susan Gault Dale 121 [email protected] Slide 1 PHA113 MPharm WEEK 26 Learning Outcomes • List the possible consequences which may happen when a dispensing error is made • Be aware of the types of errors that can occur when dispensing a prescription and...

WEEK 26 Dispensing Errors Susan Gault Dale 121 [email protected] Slide 1 PHA113 MPharm WEEK 26 Learning Outcomes • List the possible consequences which may happen when a dispensing error is made • Be aware of the types of errors that can occur when dispensing a prescription and describe the four most common types of errors • Understand why the reporting of errors and reflecting on them is good professional practice • Describe, in broad terms, the action that should be taken when an error is made • Describe what the worst course of action to take is when an error is made 2 PHA113 MPharm WEEK 26 Mrs Rosie Red 4 Front Street Gosforth NE3 4NN Amitriptyline tablets 10mg Take up to THREE at night Mitte: 28 I M Illegible 20.01.24 Dr I M Illegible The Practice 1 Front Street Gosforth NE3 4NN Slide 3 PHA113 MPharm WEEK 26 20/01/2024 4 PHA113 MPharm WEEK 26 What errors can occur when dispensing? • 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 • Giving the medicine to the wrong patient Slide 5 PHA113 MPharm WEEK 26 What is the data on dispensing errors? • National Reporting and Learning Systems (NRLS) collects incidents from community pharmacies in E + W • Data from 2005-2010 found that, of 14,704 incidents reported, the most common were: • • • • Wrong dose/strength (30.3%) Wrong medicine (28%) Wrong formulation (12%) Wrong quantity (9%) • 92% of errors did not result in any harm • < 1% (n = 29) resulted in severe harm or death Slide 6 PHA113 MPharm WEEK 26 What happens if a pharmacist makes an error? 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) • THREE separate possible consequences Slide 7 PHA113 MPharm WEEK 26 Learning from Errors • Learning from errors is one way to try and ensure they don’t happen again • 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 Slide 8 PHA113 MPharm WEEK 26 Slide 9 PHA113 MPharm WEEK 26 Common Dispensing Errors 1. 2. 3. 4. Slide 10 Similar medicine names or packaging Out of date medicine Incorrect calculation Misreading a prescription PHA113 MPharm WEEK 26 1) Similar names or packaging • Look-alike-sound-alike (LASA) errors • Account for 23% of errors reported to the National Pharmacy Association • Common similar examples include: • • • • • Allopurinol/atenolol Amitriptyline/amlodipine Indapamide/imipramine Quetiapine/quinine Ropinirole/risperidone • And many, many more • Solution: Be aware of common culprits and always double/ triple check these medicines when they are dispensed Slide 11 PHA113 MPharm WEEK 26 Examples Slide 12 PHA113 MPharm WEEK 26 Real life example – Martin White • Martin White was a pharmacist working in a small town in Northern Ireland • Ethna Walsh had an exacerbation of COPD and saw the GP who prescribed a course of prednisolone (6 daily x 5mg tablets for 5 days) • Ethna took the prescription to the pharmacy • Martin White dispensed propranolol 40mg by mistake • Within minutes of taking the first dose (6 x 40mg propranolol) she started having difficulty breathing • She was rushed to hospital but later died • In court Martin White said ‘the packaging was similar and they were next to each other on the shelf’ • He was sentenced to four months imprisonment, suspended for two years Slide 13 PHA113 MPharm WEEK 26 Real life example (cont.) Slide 14 PHA113 MPharm WEEK 26 2) Out of date medicines A pack of simvastatin has an expiry date of ‘January 2022’. When exactly does the medicine expire? a) 31st December 2021 b) 1st January 2022 c) Around the middle of the month d) 31st January 2022 Slide 15 PHA113 MPharm WEEK 26 2) Out of date medicines • Medicines may be ineffective if used after the expiry date • It is important to check the expiry date of medicines before they are dispensed • Need to remember that medicines must remain in date whilst they are being taken (e.g. simvastatin 40mg, 1 nocte x 84 – the medicine must be in date for 3 months after dispensing) • Solution: Have a regular date checking procedure to remove out of date stock and flag stock that is soon to go out of date. And check expiry dates as part of the dispensing final check procedure. • New stock received should always be put behind stock already on the shelves to ensure correct stock rotation Slide 16 PHA113 MPharm WEEK 26 3) Incorrect calculations • Common cause of error • Especially for children’s doses • mg or mcg? • Dosing in mg or mL? • Weight of child – kg or pounds? • Dilutions • Solution: Get someone else to check the calculation or take a short break and do it again. Consider if the dose seems reasonable for the patient. Slide 17 PHA113 MPharm WEEK 26 Slide 18 PHA113 MPharm WEEK 26 Peppermint Water Case • 4-days-old baby prescribed 150 mL peppermint water for infant colic • Prescription dispensed using an incorrect calculation (dilution calculation). • Multiple other failings were also noticed relating to equipment used, knowledge of staff, unclear written formula • Baby’s father administers the peppermint water and immediately realises there is something wrong • Baby admitted to hospital where he lives for two and a half weeks before dying as result of severe brain damage 19 PHA113 MPharm WEEK 26 MPharm PHA113 Slide 20 WEEK 26 Lucas Holzscheiter • London Hospital • 7 and a half months old • Was given a ten times overdose of phenytoin • miscalculated by the prescriber • not picked up by other clinical staff 21 PHA113 MPharm WEEK 26 4) Misreading prescriptions Slide 22 PHA113 MPharm WEEK 26 4) Misreading prescriptions • Illegible handwriting • Latin abbreviations poorly written or understood • mg used in dose line • Rx for an oral liquid 10mg/ml. Take 15mg....... • Labelled as ‘Take 15mL........... • What should it have been? • Sometimes the eyes see what they want to or what they expect to see • Solution: Asking another person to read the Rx Slide 23 PHA113 MPharm WEEK 26 Ranitidine Case (Part 1) • Patient was a 2 month old baby under the care of a paediatric consultant • Rx: Ranitidine solution 75mg/5ml 0.5ml tds • Pharmacist dispensed the ranitidine and labelled the medicine with the dose: ‘Half a 5ml spoonful to be taken three times a day’ • Four days after the medicine was dispensed the error was noticed by the mother • She went to the pharmacy (with the bottle) and queried the dose with the pharmacist who said it was correct Slide 24 PHA113 MPharm WEEK 26 How to handle a dispensing error • GPhC has provided guidance regarding how they expect errors to be handled –see ‘GPhC Guidance on responding to complaints or concerns’ • This should be understood as ‘What the GPhC would expect to happen’ • Patient safety is the absolute key priority • Any error needs to be handled • Honestly • Openly Slide 25 PHA113 MPharm WEEK 26 Ranitidine Case (Part 2) • The pharmacist left the mother in the pharmacy for a few moments and when he returned to her he said he had spoken to the doctor • This was untrue – he had not spoken to the doctor • He dispensed the medicine again, this time labelling it with the correct dose • The mother was suspicious, so when she got home she telephoned the doctor • She was told by the doctor’s receptionist ‘the doctor is away on holiday today’ • The mother returned to the pharmacy and confronted the pharmacist who admitted he had not spoken to the doctor • The mother immediately took the baby to A&E • Later that evening the pharmacist called round at the mother’s house and apologised for the error Slide 26 PHA113 MPharm WEEK 26 Duty of candor • This means ‘Acting with openness and honesty’ • This applies to all healthcare professionals • The ‘duty of candour’ means that healthcare professionals must: • 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); and • explain fully to the patient the short- and long-term effects of what has happened. • GPhC Standards for Pharmacy Professionals say registrants must respond honestly, openly and politely to complaints and concerns • Any attempt to be dishonest or to cover an error up will be viewed extremely poorly by the GPhC because of the poor impression it gives of the character of the pharmacist Slide 27 PHA113 MPharm WEEK 26 Dishonesty • Public confidence in any profession can only be maintained if there is trust • Trust can only occur if professionals act with honesty and integrity • Dishonesty may not always present a risk to the public but the GPhC consider cases involving elements of dishonesty as very serious • The worst thing to do when a dispensing error is made is to try and cover it up or ignore it • Making a dispensing error and being honest is better than making a dispensing error and being dishonest • It is important to take immediate action as soon as the error is identified Slide 28 PHA113 MPharm WEEK 26 Ranitidine Case (Part 3) • The pharmacist appeared before the GPhC Fitness to Practise Committee • The Chairman said: ‘Every dispensing error carries a risk to the public, but the weight of this case is not the dispensing error but that he dishonestly tried to cover it up when confronted with it’ • There was no harm to the baby • But the pharmacist unnecessarily caused the mother extra anxiety and distress • The Chairman called the pharmacist’s behaviour ‘disgraceful and wholly inappropriate’ • The pharmacist was suspended from the register for 4 months Slide 29 PHA113 MPharm WEEK 26 Further information • Royal Pharmaceutical Society • Various resources available to help with recording of errors and reflecting on them • Available at www.rpharms.com • General Pharmaceutical Council • GPhC Guidance on responding to complaints and concerns • Available at www.pharmacyregulation.org • https://www.chemistanddruggist.co.uk/CD012719/Thelegacy-of-Elizabeth-Lee • https://pharmaceutical-journal.com/article/news/bootspharmacist-and-trainee-cleared-of-babys-manslaughterbut-fined-for-dispensing-a-defective-medicine Slide 30 PHA113 MPharm