| • White Paper (4)
• MURs (2)
• Dispensing errors
• Chemotherapy
• Medication review
• Pfizer
• Locum pharmacy
Letters to the Editor
|
Dispensing errors
Society’s new criteria brought into question
From Mr P. Walton, MRPharmS
I read with renewed concern the criteria that the Royal Pharmaceutical
Society’s Council has agreed for dealing
with one-off dispensing errors (PJ, 14 April, p435). Are there any full-time practising pharmacists
(especially in a busy pharmacy) who can hold up their hands and volunteer
that they have only ever been responsible for a single error or less
in three years? I suspect that there would be no pharmacist who could
and, if my suspicions are correct and pharmacists tell the truth, they
could put themselves and their careers immediately at risk by logging
errors.
The criteria with respect to misconduct need to be looked at in conjunction
with the criteria for criminal proceedings, and guidelines make little
sense if errors that are not looked at by the Statutory Committee are
then looked at in a criminal context.
Asking pharmacy personnel to complete logs is effectively asking them
to incriminate themselves, which in most circumstances would be inadvisable.
There seems to be no exemption from referral for misconduct even when
the prime cause of the error is well known or has previously been reported
and is correctable but has not been corrected. Earlier this year, I
wrote a letter to The Journal regarding decriminalisation (13 January, p47)
in which I asked “What use is reporting dispensing errors if nothing
is then done?”. The content would still be true if I had written
it today.
I have heard of a company disciplining a member of staff who reported
minor errors where there was a well known cause, even though the error
had been corrected before the medicine was being dispensed. (It was in
the protocol that such potential errors were reported.) The error was
taking from shelves boxes that looked similar but contained different
medicines.
Nobody seems to want to take pharmaceutical companies to task for their
desire to have a unified image, colour scheme and logo on their product.
Yet this a contributory factor in dispensing errors and has caused concern
for many years. Of course a pharmacy company sees logs of errors and
can dismiss or otherwise punish personnel, even when its own actions
or negligence may have contributed to the errors.
There is nothing in the Society’s criteria stating staff have to
log preconditions likely to cause error but which have not resulted in
actual error. How many pharmacists have walked into intolerable dispensing
conditions, and possibly even complained about the conditions to the
company (with risk to their own job) — without a log of the complaint
having to be made? What is needed is an independent complaints body that
employees can use to protect themselves from the actions of their employers,
otherwise the employers could effectively deal with logged problems and
potential problems by removing or otherwise demoting any member of staff
who reports or complains.
I suspect that the criteria for misconduct were devised by pharmacists
who do little dispensing themselves and so are unlikely to be at the
receiving end of any consequences. For the reasons elucidated above these
criteria represent the antithesis of the no-blame or fair-blame culture.
Philip Walton
Manchester
| |
The Royal Pharmaceutical Society declined an invitation to respond.
— EDITOR
|
|
The
Pharmaceutical Journal