Dilemma results: methadone error

WE recently published a dilemma about a methadone dispensing error. The dilemma posed a number of questions throughout, with the purpose of exploring what you would do under the circumstances and if you would change your mind when presented with alternative scenarios.

We have given a brief recap of the dilemma below. If you missed it first time around, you can participate here.

You are the manager of a busy pharmacy with around 30 patients for whom you dispense methadone. It’s a Friday morning and one of your patients (patient 1) comes in to collect his methadone — your dispenser gives it to him and observes him swallow that day’s dose and gives him the next two doses away with him for Saturday and Sunday.

A few hours later another methadone patient (patient 2) comes to collect his. However, you can’t find his methadone in the CD cabinet. Your dispenser remembers dispensing it in preparation, and you remember checking it. It dawns on you there has been an error.

On checking, you notice that patient 1 has been given patient 2’s methadone away with him and he has also consumed patient 2’s dose for today. You do not have a prescription for patient 1 — it was due to be handed in later today.

The results:

On a scale of 1-5 (where 5 is very serious), how serious is this error?
1   1.9%

2   0.3%

3   2.6%

4   16.7%

5   78.5%

You realise that patient 1 has consumed 40ml of methadone today, but his prescription is normally only for 20ml daily. He also has two further bottles each containing 40ml of methadone.

Would you attempt to contact patient 1 to explain and make sure he is OK?
Yes 99.4%

No 0.6%

While there are many implications as a consequence of this error, the patient’s safety has to be the primary concern. Would your decision to contact the patient be different if the quantity of methadone error was different?

When would you contact patient?
Always (regardless of how small the excess volume)  89.4%

5ml excess or more  6.1%

10ml excess or more  3.5%

15 ml excess or more  0%

20ml excess or more  1%

In addition to the patient, who (if anyone) would you inform about the error?*
Nobody  0.8%

GP  33.8%

Superintendent pharmacist  30.8%

GPhC inspector  1.7%

Accountable officer  21.5%

Pharmacy insurer  11.4%
(* 5 votes allowed per person)

Would this decision change depending on the volume of the error?
No  72.7%

Yes  10%

Perhaps if volume was smaller  17.3%

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