Pharmacy law and ethics 7: dispensing and errors

What are near misses?

when an error is identified and corrected before it actually reaches the patient

What is a dispensing error?

when the error actually reaches the patient

What are the implications of dispensing errors?

- On a patient = obvious safety errors

- On a pharmacist = criminal prosecution - they could be subject to a fitness to practise action, disciplinary action by the NHS and they can be sued by the patient

How would you reduce the risk of error? 3

standard operating procedures for the supply of medicine are in place and that they're regularly used, evaluated, and reviewed

- not just one person as a sole dispenser and checker of the medicine

- You want to ensure that medicines of similar sounding names or with similar packaging are not placed next to each other on the self

-reporting

maintaining a medication error log, monitor near misses

- work environment, look at dispensary layout to see if you can reduce risk

- issue around ability to concentrate.(nosie levels)

Why would the patient take the matter further?

- the error has been made at a pharmacy, which many members of the public believe should work 100% accurately, may be a reason why they think they need to take the matter further. Because it proves that there isn't 100% accurate

- Also, a patient may have been harmed by that error and therefore may want a further investigation

- Or a patient is dissatisfied with the way in which the error was dealt with in the pharmacy

- So, maybe there wasn't a clear, transparent owning up of the error and explanation of how it happened or any kind of effort to resolve anything, really, that happened.

What thresholds do cases have to meet to be referred to the investigating committee?

- there is either moderate to severe harm, which was avoidable;

- there was a deliberate attempt to cause harm;

- there was failure to act when necessary to protect the safety of the patient;

- there are unsafe working practices;

- and also, the pharmacist is unfit to practice safely

What did the pharmacy preparation and dispensing errors - registered pharmacies order (2018) change for pharmacies who made a error?

- before, an error was classed as a criminal offence

- this law change prevents the automatic criminalisation of dispensing errors for pharmacists

whaty is done when an error has been made?

• standard 1: open and honest

• standard 2: report

• standard 3: learn

• standard 4: share

• standard 5: act to change practise

• standard 6: review changes to practise

how do we handle dispensing errors?

• 1. Take steps to let the patient know promptly 2. Make things right (this may involve contacting the prescriber)

• 3. Offer an apology

• 4. Let colleagues involved in the error know.

legal defence?

legal defence can be used when error has been in (4 requirements )

• its done to reducing the risk of prosecution you reduce the fear of reporting errors.

• in a registered pharamcy,

• by or under supervision of a registered pharmacist

• upplied on a valid prescription, PGD, or prescriber’s direction

• Patient informed promptly once the error is known

GPhC Fitness to Practise – Process Overview

• Concern raised

• Facts gathered – speak to those involved, site visits, collect evidence

• Review against threshold criteria

• Decision:

  • If serious → refer to Investigating Committee or Fitness to Practise Committee

  • If not serious → may close or issue advice/guidance

GPhC Threshold Criteria – When a Case Is Referred

🔹 Risk to patient/public safety
🔹 Undermines trust in the pharmacy profession
🔹 Serious or repeated failure to meet professional standards
🔹 Dishonesty or lack of integrity
🔹 Health issue that affects safe or effective practice
🔹 Public interest requires further action

what are the error types and error causes ?

Error Types

• Selection errors

• Labelling

• Bagging errors]

Error Causes

• Misreading the prescription