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Similar branding partly blamed for ‘devastating’ dispensing error

Community pharmacist sentenced for dispensing the wrong medicine spoke of ‘cramped working’ conditions and problem of similar packaging.

An “overworked” community pharmacist, who pleaded guilty to dispensing the wrong drug to a patient who later died, has been sentenced to four months imprisonment suspended for two years.

Martin White of Belfast Road, Muckamore in Northern Ireland, mistakenly dispensed propranolol instead of prednisolone, having told investigators that the two packages were “side by side on the shelf and have similar branding”.

The 45-year-old was sentenced at Antrim Crown Court on 16 December 2016.

White admitted at an earlier hearing on 6 December 2016 to an offence under section 64 of the Medicines Act 1968, that he had “supplied a medicinal product in pursuance of a prescription given by a practitioner, which was not of the nature or quality specified”, to the prejudice of Ethna Walsh.

Passing sentence, Judge Gordon Kerr said dispensing the wrong drug for Walsh’s chronic obstructive pulmonary disease resulted from a combination of factors, including a single momentary lapse in concentration.

Kerr also acknowledged that Walsh’s death has had a devastating effect on her family and said the damage and injury caused by the pharmacist could not be higher.

The pharmacist’s degree of culpability was the result of “poor professional performance, but not professional misconduct”, Kerr said, adding that there was “no evidence of intentional negligence”.

However, given the cumulated effect of White’s guilty plea, previous good character, loss of reputation and career and permanent financial loss, Kerr said he did not feel an immediate custodial sentence was necessary.

At the hearing on 6 December 2016, the court was told how the tragedy unfolded.

Walsh went to the Clear Pharmacy on Station Road in Antrim with her husband on 6 February 2014. Instead of being dispensed the steroid prednisolone for which she had a prescription, the couple were mistakenly given a box of propranolol.

Prosecutor Michael Chambers told the court that, once home, Walsh took some of the tablets, but within moments had difficulty breathing. She was rushed to hospital, but later died.

Chambers added that White later told the police that he “must have mistakenly picked up the propranolol instead of the prednisolone”, adding that the two boxes were positioned next to each other on the dispensary shelves and have similar packaging.

While White claimed that he had carried out the required checks under the pharmacy’s standard operating procedures (SOP), he had also complained of the “cramped working space”, and that at the time he had been to see his own GP about feelings of low mood, tiredness and fatigue.

An expert, named in the judgement as Dr Maguire, who later examined what happened told the court that the SOP was deficient as it did not require a final check by a different member of staff.

The expert concluded that White was guilty only of “poor professional performance” as opposed to “professional misconduct”.

Defence lawyer John Kearney described White as a man with a hither to unblemished character who was acutely aware he was responsible for the tragedy “and will carry it for the rest of his life”.

Kearney also suggested at the earlier hearing that what had happened occurred because White was “an ordinary man who struggled because he worked too hard… regularly working up to 60 hours a week… always on call”.

He added later White himself acknowledged he was working too hard and that there were “systematic failings within the pharmacy”, but it “was a single mistake in 24 years of doing this job day in, day out, week in, week out… dispensing thousands of prescriptions”.

Kearney revealed that since the tragedy, White has been too “frozen in fear” to return to work, and was “racked with guilt and destroyed with remorse” and has been receiving psychiatric help.

After the sentence was passed, Walsh’s family called on community pharmacists to learn “the hard lessons” from her “unnecessary death”.

In a statement, the family said they hoped “that some good will come of this tragic event”, and that community pharmacists follow new recommendations in preventing dispensing errors, in the hope that “other families will be spared the burden of pain, anguish and loss they have had to shoulder”.

Martin Astbury, president of the Royal Electronicjuice, which has campaigned for the decriminalisation of dispensing errors, says the error had “tragic consequences for all concerned”.

“Like all pharmacists I would like to see more done to make sure one simple mistake can’t lead to such devastating harm to patients and their families,” he says.

“This case highlights that all pharmacists carry a huge responsibility in ensuring that dispensing is as safe as possible, as well as the consequences patients and pharmacists experience when things go wrong.”

Astbury adds that a balance needs to be struck between sharing and learning from errors without undue fear of sanction and ensuing that the public has confidence that pharmacists will be held to account for their actions. “Where an individual has acted deliberately or negligently, for example, there is no doubt they should experience the full weight of the criminal law.”

But Astbury adds: “We strongly believe that patient safety will be improved if the threat of automatic criminal prosecution is removed from dispensing errors because more people will report, share and learn from, their mistakes. A more open and learning culture will help improve patient care.”

Citation: Electronicjuice DOI: 10.1211/PJ.2016.20202128

Readers' comments (3)

  • So what have we?
    First, Prenisolone/Propranolol AGAIN.
    Second,the law gets invoked, rather than just a 'compensation/insurance-company' pathway.
    Third, Pharmacist gets suspended sentence.
    Fourth, cramped conditions, long hours, are mentioned.
    How far have we come? Have we moved AT ALL on 'decriminalising of . . .'?
    I am amazed at the number of scripts that a pharmacist does per month, and the contract is still based on quantity and quantity.
    With the recent 'cuts', it seems likely that a pharmacy might want to cut its over-contract hours of opening, so that, instead of having two pharmacists to cover the long hours, we might want to do it with one pharmacist doing even longer hours.
    Then we have peer-pressure to deliver, get scripts from surgeries, and put the stuff into nomad-trays (or the current name), then the pressure to do MURs. And I'm sure we all have to break up our dispensing to give patients an estimate of time taken and availability, and spend time on children with runny noses (and headaches, if you read the PJ!).
    I qualified in 1968, and retired in 2007. But, apart from 'dispensing' nowadays being more in terms of dishing out packets of 28 tablets, rather than making Mist Aspirin pro Inf, we don't seem to have made much progress.

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  • Who dare comment when there is the fear that anyone could make the same mistake again? And yet there is no doubt that a clear system followed at all times of a 3 way check greatly reduces the risk (different people print labels, pick up, and make a final check). But is there not also a case for advertising to the public that the person taking the tablets should also check the packaging, and should be encouraged to query with the pharmacist any doubts which they may have?

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  • As an elderly patient with LTCs I could not agree more with the comment made by Peter Craske. Of course, patients should check the contents of the pharmacy bag containing their prescribed medications. Never in my long practice of "being curious", have I encountered a disparaging look from the dispensing pharmacist. On the contrary, my patient safety action has led to very interesting conversations on medicine optimisation and general awareness amongst the general public of the risks of drugs, both prescribed and OTCs.

    I wish we could all find ways to express our support to Martin White.

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