The Pharmaceutical Journal
Vol 279 No 7460 p45
14 July 2007

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Letters to the Editor

Dispensing errors

Type of error and response of pharmacist that matters

From Mr M. Randerson, MRPharmS

I write with reference to the Law and Ethics Bulletin (PJ, 30 June, p781) on medication error logs. The criteria for referral of a single dispensing error to the Investigating Committee all make perfect sense in defining a potentially poorly performing practitioner — “cover up, failure to co-operate, no attempt to learn from”, etc, — with one noticeable exception, in my view.

I understand that “the potential for, or evidence that, the dispensing error caused moderate or severe harm or death” is of obvious interest to patients and the public in general and might be thought by them to equate to a poor practitioner. However, I fail to see why the different potential consequences of, for example, dispensing incorrect strengths of two prescriptions, one for a drug with a narrow therapeutic window and one for a drug much less toxic, should result in different fitness-to-practise processes and decisions by the Royal Pharmaceutical Society.

Surely it is the type of error and the response of the pharmacist to making the error that matters — not the intrinsic toxicity of the drug involved.  

Mark Randerson
Scarborough, North Yorkshire

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