Criteria for assessing whether a single dispensing error may amount to misconduct

The Council agreed that single dispensing errors should not be referred to the Infringements Committee without evidence of at least one of the following indicators of professional misconduct:

• Moderate harm, severe harm or death (as defined by the National Patient Safety Agency for grading patient safety incidents) or the potential for one of these

• A deliberate attempt to cause harm to patients or the public

• Ill health or substance abuse by the pharmacist

• The taking of an unacceptable risk by departure from agreed safe protocols or standard operating procedures

• Absence of systems to record errors in the pharmacy (which should result in the superintendent pharmacist or pharmacy owner being referred)

• A failure to make an error log entry (if aware of the error)

• Absence of systems to learn from errors in the pharmacy (which should result in the superintendent pharmacist or pharmacy owner being referred)

• A lack of any attempt to learn from the error

• A failure to implement previous advice from an inspector that would have prevented the error

• An attempt to cover up the error

• A failure to co-operate with an investigation by a Society inspector or other investigator

• Other misconduct that would form the basis of a complaint

• A failure to apologise or provide an explanation to the patient or the patient’s representative (if aware of the error)

• Relevant history within the previous three years