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The consequences of not preventing errors in the pharmacy

  • June 18, 2009
  • RPh on the Go

As pharmacist, we are inundated with stress and pressure from our daily work. Often, there isn’t much we can do to eliminate that stress. But two recent court cases, in the US and UK, make it clear that the stakes for dealing with that stress have just gone up considerably.

In April 2009, a pharmacist was prosecuted under British law, the 1968 Medicines Act, for dispensing a wrong drug. This pharmacist was sentenced to three months in jail. The patient died of receiving beta-blockers instead of steroids. The pharmacist was not found legally or factually responsible for the patient’s death but was given a suspended prison sentence to qualify the gravity of the offense.

You might think that’s a rare situation in a foreign country, but an Ohio pharmacist earlier this month pleaded guilty to involuntary homicide for not properly reviewing the chemo dose a tech prepared. The dosage turned out to have a 23% saline base, rather than a 1% saline base, and a child died.

Now, you may ask, “How does this effect me?” With no tort reform, you will have lawyers finding ways to litigate against a pharmacist. You just wait and see. The cause of the dispensing error in the UK is the same here in the states. Typically, most pharmacists will experience pressure from the customers, high volume of prescriptions, long hours, staffing, and other distractions. In otherwords: being overworked.

Our job entails maintaining patient safety. With all the pressures to our profession, I would think making a dispensing error as a criminal offense may lead to more errors and undue stress. I wouldn’t be surprised to see some mild form of OCD and paranoia. Pharmacists would be double and triple checking their work. The waiting time would be ridiculously long.

Of even greater concern is the Ohio case, where the root cause of the incident was an inexperienced tech. A bad pharmacist then compounded the error by not listening to the tech’s misgivings. The case spurred efforts in Ohio to require certified pharmacy technicians in all hospitals, but even without a law, it’s worth thinking about–are you surrounded by the best and the brightest?

As pharmacist, we must discuss our concerns with upper management or our immediate supervisor. It is important to work in an environment that minimizes problems that are a detriment to our profession. As pharmacists, and as the people ultimately responsible for the drugs coming out of our pharmacies, need to voice our concerns because it will take only one major catastrophe to spoil the whole lot of us.

Cyrus Pacis is a pharmacist who often works on long-term relief pharmacy jobs through RPh on the Go.

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