A dispensing error through the eyes of the pharmacist

Johnathan Laird
Johnathan Laird

TO make an error is a human trait.

A pharmacist I used to work with once told me that you should worry about all dispensing errors. However, it is the errors that you never become aware of that should worry you most.

For a pharmacist this is a chilling thought.

I have made dispensing errors.

To a lay person the sentence above may appear innocuous. However, as the law stands at the moment an admission of this nature could lead to criminal proceedings. For the majority of pharmacists it never comes to this, because the harm caused is either non-existent, not clinically significant, or cannot be attributed to the error.

Minority
It is the minority of pharmacists who suffer the criminal consequences of making a dispensing error. I highly recommend you read this story about a dispensing error which, very unfortunately, led to the death of a patient three days later. The judgement in that case was made and this blog is not about questioning it in any way. I would like to explore how that moment and the days and weeks after may have felt for any pharmacist in a similar situation.

Making an error
The first clue is often the patient walking up the shop towards the dispensary with an already, crumpled, previously opened dispensing bag.

Your pulse quickens.

Could this be your career ending moment?

Wrong medicine
The patient asks to speak to the pharmacist. You oblige promptly, heading over with a quiet sense of impending doom. The box is presented and you take a look. It appears at first glance that there is nothing wrong, because it looks like a felodipine box.

But, it turns out that the felodipine is actually a box of co-tenidone, which looks very similar. Your mind goes into overdrive as you will the whole situation to just disappear. It does not. The root cause analysis begins immediately. Human nature is such that you seek to blame. It is at this point that I fall back on my instinct for professionalism.

First things first
My only concern at this stage is the patient. Luckily they tell you that in this case none of the incorrect medicine has been taken. You have already made the error, so making things right for the patient is really important.

In my view you should always apologise.

It is then about reporting the error, completing a thorough root cause analysis and sharing findings with your team. These are all processes that must be completed to meet our professional obligations. How you feel after making an error is another matter. I’m quite sure that every pharmacist copes in individual ways, but cope they must.  The feeling after I make a dispensing error is horrible. I feel professionally exposed in these situations. It feels like I have failed the patient that I work so hard to proactively protect. It can feel like a rug being whipped from beneath me.

Next time
The relative certainty about dispensing errors is that no excess of optimism or denial will wash away the cold hard fact that there will be a next time, or that the next time the error could have serious consequences. I fend off this anxiety by redoubling my efforts into making things as safe as I possibly can in the dispensary.

As you may know, in Scotland a series of Pharmacy Quality Roadshows will be supporting the introduction of quality improvement methodology in community pharmacy to strengthen an embed continuous quality improvement. This is an excellent initiative that really could lead to improvement in many areas of community pharmacy.

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About johnathanlaird 443 Articles
Community pharmacist. Independent prescirber. Interested in respiratory care and prescribing from within the community pharmacy.