POMs 8 - Dispensing Errors

Question 1

What is a dispensing error? (1)

Answer 1

An error made during the dispensing process from receipt of the Rx through to the supply of the dispensed medicine, where the error means the patient receives a medicine which differs from what’s intended by the prescriber.

Question 2

Give e.g. of dispensing errors. (5)

Answer 2

Incorrect labelling

A medicine intended for another patient being dispensed to the wrong patient.

The wrong medicine dispensed.

Medicine being dispensed at the wrong strength or in the wrong dosage form.

Supply of an out of date medicine.

Question 3

Why should errors be decriminalised? (1)

Answer 3

Pharmacist would have committed a criminal offence if a dispensing error is made.

Question 4

What does Pharmacy Order 2018 state about dispensing errors? (1)

Answer 4

It provides a statutory (legal) defence which could be used if a dispensing error is made.

Question 5

What are the main features of legal defence? (9)

Answer 5

Medicines are prepared by a registrant (pharmacist or PT) or acting under their supervision AND

Medicines were supplied from a registered pharmacy premises AND

Registrant was acting in the course of their profession AND

Medicines were supplied in a Rx or from the direction of a prescriber AND

If you are aware of the error there was a prompt error notification.

If all above apply, this is the legal defence.

However, if the intention was to cause harm or criminal negligence was suspected = criminal sanctions apply.

Accountability is important

GPhC states that it’s unlikely that a single dispensing error would result in a FtP committee referral unless aggravating factors were present.