Authored article

Delivering a better solution to dispensing errors

Dr Keith Ridge CBE, Chief Pharmaceutical Officer for England, urges people to give their thoughts on the consultation on dispensing errors.

This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government

We underestimate the vital role our pharmacy teams play in healthcare. As well as providing critical health advice to patients and an array of services from flu vaccinations to smoking cessation, they of course dispense medicines, scrutinise and check prescriptions. Pharmacists and their teams are the final gatekeepers in the medication process – they have to be satisfied that the prescription is for the right drug, in the right dose, for the right person.

The vast majority of the 1 billion prescription items dispensed from community pharmacies annually are done so without harm or incident. But errors sometimes happen. Everyone can learn from mistakes, but this learning has to take place in a supportive environment, and one where pharmacists and pharmacy technicians do not fear criminal prosecution for mistakes made in good faith. Among healthcare professionals this threat of criminal prosecution for ‘inadvertent errors’ is one that especially hangs over pharmacy professionals as the main dispensers of medicines.

So it’s perhaps not surprising then that dispensing errors are not reported as routinely as they might be – meaning that there may not always be learnings from mistakes made. Transparency and openness in healthcare was a major theme in the Government’s recent ‘Culture change in the NHS’ report – which sets out the progress made in creating a safer, more honest NHS that learns from when things go wrong.

It is of course right and proper to have legal consequences for a deliberate disregard to patient safety, but a balance must be struck between reprimand and education and risking a culture where individuals fear career-ending mistakes.

That’s why the Department of Health and the other three UK health departments, on behalf of the Rebalancing of Medicines Legislation and Pharmacy Regulation Programme Board, launched a consultation into dispensing errors and standards for registered pharmacies this month. It recognises the need to find more positive approaches to identifying and remedying mistakes. The board is drawn from patient representatives, regulators, the four countries of the UK, professional and trade bodies. The changes being consulted on will redress ‘imbalances’ between legislation and regulation. They will bring pharmacists and pharmacy technicians more in line with how errors made by other healthcare professionals are handled.

By giving pharmacists and pharmacy technicians a defence to the criminal sanction on dispensing errors, we will improve reporting of patient safety incidents, share learning and stop mistakes happening again.

Work carried out by the Medicines Governance Group at the North Bristol NHS Trust epitomises this. Strong leadership by the director of pharmacy led to the establishment of a multidisciplinary group that meets every two months and reports to the hospital’s Drugs and Therapeutics Committee. The group provides monthly updates to the medical director, nursing director, chief executive and trust board. It also produces a ‘top tips’ bulletin focusing on a different issue in each edition, such as medicines-related ‘never events’.

As an ex-hospital pharmacist, I know only too well how disappointed hospital pharmacy colleagues will be that this first consultation does not apply to them. I would like to reassure hospital pharmacy colleagues that proposals are in development, which the Programme Board is keen to bring forward at the earliest opportunity. In the meantime I would encourage you to continue, and build on, the great work already done in hospital pharmacy to improve patient safety.

Meanwhile, pharmacy in the community is taking a lead in promoting better reporting and a culture of learning and development. Pharmacy Voice, a trade association, analysed data from community pharmacies in England in 2013 and identified a common error in relation to chloramphenicol eye drops. This was discovered when Pharmacy Voice used its pharmacy superintendents group to regularly talk ‘safety’. Chloramphenicol is a common ophthalmic antibiotic treatment. It is also produced in dropper bottles for acute infections of the middle ear. Although risks associated with topical chloramphenicol preparations have long been recognised, transposition incidents continue to persist due to the similarity of liquid preparations, including packaging. There is an important difference between a chloramphenicol preparation intended for the ears and one for the eyes.

Pharmacy Voice carried out an audit of the number of dispensing incidents involving topical chloramphenicol preparations. Data collected from 5,464 community pharmacies revealed 42 incidents in 2013. Extrapolation suggests that around a hundred potential chloramphenicol dispensing incidents may have occurred in England that year.

On the basis of this evidence, Pharmacy Voice raised their concerns with the Medicines and Healthcare products Regulatory Agency – the regulator of medicines – to see what changes to product packaging could be implemented to limit the risk of further incidents. Approaches like this, where shortcomings in processes are given as much weight as individual human failings, offer broader solutions to the issue of error reporting. If more can be done to support pharmacists and pharmacy technicians in their work, not least their learning and development, then errors in dispensing can become even rarer than they already are and patients will be safer.

I urge you to get involved in this rebalancing pharmacy consultation, which runs until 14 May. There are a number of events and online engagement activities where you can give you views. Details of these can be found here

Keith Ridge
Published 27 February 2015