Former locum handed

suspended jail term for

dispensing error
The Pharmaceutical Journal, 6 APR 2009
A former locum pharmacist has been sentenced to a three-month jail term,
suspended for 18 months, following a dispensing error. The judge also
ordered the defendant to complete a 12-month supervision requirement with
the probation service.
Elizabeth Lee, of Victor Road, Windsor, Berkshire, who was working at a
Tesco pharmacy, mistakenly dispensed propranolol instead of prednisolone
for 72-year-old Carmel Sheller, who died three days later in hospital.
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The court heard on 2 April 2009 that Mrs Lee was working 10-hour shifts
without a break when she supplied the wrong drug.
The judge said Mrs Lee bore no factual or legal responsibility for Mrs
Shellers death, which a pathologist had determined was due to Mrs
Shellers underlying long-term illness.
However, he said: The public, just as the Sheller family were, are entitled to
expect the highest standard of care from those responsible for the dispensing
of medication.
That is why the offence exists as a criminal offence punishable with
imprisonment.

He continued: Everything that I have read and heard about you, and indeed
your family, indicates that you as an individual and as a family are decent
people with consideration for others, who in ordinary circumstances would
not have come anywhere near a court like this let alone intentionally break
the law.
Also I have been impressed and act upon what I have been told you did back
in September 2007 when this matter came to light.
You have not sought to avoid responsibility, you did not then and you have
not now.
It is worthy of note that you resigned from the Royal Pharmaceutical
Society immediately and I am told and accept you will not seek again to work
as a pharmacist.

Gravity of the offence necessitated prison sentence

The judge said a prison sentence needed to be imposed to mark the gravity
of the offence but her circumstances had persuaded him to suspend it.
Her barrister Christopher Hudson said Mrs Lee was overworked at the
pharmacy where two members of staff were on maternity leave.
The judge was handed a sheaf of glowing references for Mrs Lee.
Almost without exception those witnesses who worked with her at Tesco
speak of her professionalism, her thoroughness, her character, said Mr
Hudson, who added: She worked long and arduous shifts.
There was no break because the pharmacy could not function without her
presence.
Mr Hudson said it is still not clear who dispensed the medicine.

Ultimately it was her responsibility to check and make sure no error was
made and although an error was made it was a genuine error under pressure.
Mrs Lee admitted supplying a medicinal product with a misleading label on
the package a charge brought under the 1968 Medicines Act.
She had been due to face trial on a further charge of supplying a medicinal
product that was not of the nature specifically prescribed. But after legal
arguments her plea was accepted by prosecutors. The second charge against
her will remain on file.

Son of the deceased hoped for manslaughter charge

Speaking after the sentence Charles Sheller, Mrs Shellers son said: The
sentence is not all that we would have hoped for but we understand the
judges position.
The pathologists report did not go to our favour and the manslaughter
charge was dropped. In an ideal world we would have had the manslaughter
charge.
Asked about the manpower problems at the pharmacy, Mr Sheller said Mrs
Lee should have spoken to her employers if she was concerned.
She was the professional in charge. She was the person in the white coat we
as the public trust, along with our doctors. You are trusting they have done
their job.
See also Dispensing errors should be decriminalised
Citation: The Pharmaceutical Journal, Vol. 282, p401 | URI: 10882780

Ann Pharmacother. 2003 Jan;37(1):87-9.

Dispensing error leading to alendronate ingestion.

Carrire B1, Bailey B, Chabot G, Lebel D.
Author information
Abstract
OBJECTIVE:
To report a case of medication dispensing error by administration of similarly packaged drugs.
CASE SUMMARY:
A 6-year-old East Indian boy with asthma was mistakenly given alendronate, a bisphosphonate, for 3
months instead of montelukast, a leukotriene-receptor antagonist. Symptoms of esophageal irritation
developed and disappeared on discontinuation of alendronate.
DISCUSSION:
Alendronate and montelukast have very similar packaging and are available in dosages that also can be
similar for some patients. Alendronate caused symptoms of irritative gastritis in this child before the error
was identified. This case report emphasizes one of the possible sources of medication dispensing errors:
a mistaken identification due to similar packaging (confirmation bias). Manufacturers can help to prevent
medication errors in many ways; in this case, more distinct packaging would have decreased the risk of
error. A standard bar-coding scheme among manufacturers could lead to an important improvement in the
safety of medication dispensation. Practitioners are also encouraged to report such errors to the United
States Pharmacopoeia Medication Errors Reporting Program.
CONCLUSIONS:
With increased awareness of medication errors, healthcare practitioners, manufacturers, and patients
should take precautionary steps to prevent dispensing errors and their consequences.
PMID:

12503941

[PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/12503941?report=abstract

15k recovered after insulin dispensing error by

pharmacist
Boyes Turner medical negligence solicitors have recovered 15,000 for Naomi, in relation to
a claim following a dispensing error involving insulin.

Naomi is an insulin dependent diabetic who has to take insulin throughout the day and at night.

On 31st December 2010, she obtained a repeat prescription from her GP practice for her short-acting
insulin. She took the prescription to the pharmacy near to the GP surgery. However instead of being
dispensed the correct insulin as prescribed, a locum pharmacist gave her the wrong insulin cartridges.

The dispensing error caused Naomi to receive an underdose of insulin which meant that her high blood
sugar following meals was not blunted to the same extent. She also received an overdose of
intermediate acting insulin which she was not supposed to take at all.

Throughout January 2011, Naomi's blood sugar levels were up and down. She felt unwell, tired and
lacking in energy. Her legs felt heavy and she struggled to get out of bed.

On 31st January 2011, she suffered a major hypoglycaemic episode and fell, suffering a dental and jaw
injury.

Court proceedings were served against the pharmacy and the locum pharmacist in May 2012.

Defences were received from both defendants, essentially blaming the other for the mistake.

The pharmacy admitted that the incorrect medication had been picked off the shelf by the dispenser
but the locum pharmacist had a responsibility to check that the correct medication had been picked
from the shelf.
- See more at: http://www.claims-medneg.co.uk/our-cases/prescription-and-medicationerrors/insulin-dispensing-error-pharmacist#sthash.ykE9jJR4.dpuf

http://www.claims-medneg.co.uk/our-cases/prescription-and-medication-errors/insulin-dispensingerror-pharmacist

(02HDC04619, 10 February 2004)

Pharmacy ~ Pharmacist ~ Trainee technician ~ Dispensing error ~ Rest home ~
Standard
of
care
~
Medication
checks
~
Rights
4(1),
4(2)
An 82-year-old rest home resident had her medication prepared into blister packs by
a pharmacy. Blister packs involve the medication being prepared and dispensed at
the pharmacy from a doctor's prescription. Each dose of medication is placed into a
tray and checked by the pharmacist, then the pack is sealed with a foil overlay. In
this case, the blister packs were prepared by a trainee technician and checked by a
pharmacist. A nurse at the rest home then checked the medication listed on the
blister pack against the medication prescribed by the resident's general practitioner.
The resident was given two blister packs per day, one in the morning and one at
night. The nurse on duty gave the blister pack to the resident who, upon opening it,
noticed that one of the pills was green, and looked different from the one she
normally took. She alerted a staff member, who checked it and told the resident she
could
take
it.
Soon after swallowing the tablet the resident vomited. Her GP visited and treated
her for side effects of taking pergolide (a treatment for Parkinson's disease), which
had been dispensed instead of perhexiline (treatment for angina). The blister pack
was corrected by the pharmacy manager that morning. However, that evening the
resident was again given a blister pack containing the incorrect tablet. She did not
take the tablet and, next morning, alerted her daughter, who ensured that the
pharmacy manager changed her mother's evening blister packs as well. The
resident's daughter complained about the service provided by the pharmacy.
It was held that the trainee technician who prepared the blister pack was in breach
of Rights 4(1) and 4(2) of the Code as, even though she was working under
supervision, she was still accountable for her actions, and was required to follow
professional
standards.
The pharmacist breached of Rights 4(1) and 4(2) of the Code in not checking the
contents of the blister pack, and failing to detect the medication error. When
advised of the error, the pharmacy manager acted promptly, but failed to ascertain
whether all the resident's blister packs were correct, so compounding the error.
The registered nurse on duty in the rest home was responsible for checking that the
blister pack medication was correct, and failed to do so. Contrary to the rest home's
policy and good nursing practice, she relied on the integrity of the checking process

within

the

pharmacy,

and

thus

breached

Rights

4(1)

and

4(2).

The pharmacy and rest home both had adequate policies and procedures for the
dispensing and checking of medication, and it was reasonable to expect staff to
adhere to such protocols.
http://www.hdc.org.nz/decisions--case-notes/case-notes/dispensing-error-(02hdc04619)

Warfarin dispensing error (03HDC13660)

Download Warfarin dispensing error (03HDC13660) (PDF 11Kb)
(03HDC13660, 17 February 2004)
Pharmacist ~ Pharmacy ~ Professional standards ~ Dispensing error ~ Right 4(2)
On discharge from hospital, an 81-year-old gentleman was given a prescription for
his multiple medical problems. The patient and his daughter collected the
medication from the pharmacy on their way home. The medication was dispensed in
blister packs, where all medication to be taken at a particular time is dispensed into
individual
compartments.
The next day the man advised his daughter that his medication appeared to have
changed. Instead of one (3mg) warfarin tablet he now had three tablets. He had
never previously been given more than 5mg. His daughter decided not to telephone
the hospital because she was never able to get hold of the doctor who prescribed
the medication. She advised her father that the doctor must know what he is doing
and
to
take
the
medication.
Six days later the patient's daughter noticed that her father was bleeding from
scratches on his feet, and she telephoned their general practitioner. The general
practitioner saw the patient that day and determined that on discharge he had been
prescribed only 3mg warfarin. The patient's INR (a blood test to determine clotting
time) was greater than 10 (therapeutic range 2.0-3.0). The patient was admitted to
hospital for administration of vitamin K to reverse the anti-clotting effects. This was
successful but the patient's previous medical problems resurfaced and he died
several
weeks
later.
The patient's daughter raised the matter with the pharmacist, who accepted the
error and was upset and apologetic. He had incorrectly entered the figure 3 into the
computer to denote how many 3mg tablets were required each day. The pharmacist
also failed to check the print-out against the prescription, and had made up the
blister packs against the print-out rather than the prescription, contrary to the
pharmacy's dispensing policy. He was held to have breached Right 4(2).

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Quicklinks

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http://www.hdc.org.nz/decisions--case-notes/case-notes/warfarin-dispensing-error-(03hdc13660)
HEALTH AND DISABILITY COMISSIONER

Real clients we have helped with prescription error claims

Prescription error claims we have dealt with
In the past, Thompsons Solicitors have dealt with many clinical negligence cases where patients have been harmed
due to errors made with prescription drugs. Below, you will find just two examples of claims we have successfully
handled to recover compensation for the injured person.
GP prescribed medication patient was allergic to
Our client in this case was a man who suffered from psoriasis and when he developed an infection, the dermatology
clinic advised his GP to prescribe him with some antibiotics.
Despite the fact that it was well documented within his medical notes that he was allergic to penicillin, his GP
prescribed him with penicillin-based antibiotics.
The man took the prescription drugs and suffered an allergic reaction. His psoriasis worsened and he was in pain.
He had to be admitted to hospital for 10 days while his symptoms were brought under control.
Thompsons Solicitors' clinical negligence team successfully made a claim for compensation on behalf of the injured
man as his GP should have seen from his medical records that he was allergic to penicillin and prescribed an
antibiotic which was not penicillin-based.
Wrong Medication dispensed by chemist
In this case our client was a 72 year old gentleman from the Midlands who had recently had gall bladder removal
surgery. He was given a prescription for Omeprazole which was prescribed for a pre existing stomach condition and
his wife attended a very well known chemist to collect the medication for him. The medication was placed in a sealed
bag and our clients wife reasonably took it for the medication as prescribed.

However, after taking several dosses of the medication, our client began to suffer symptoms of dizziness, problems
sleeping, blurred vision, acid reflux and muscle ache. Our client continued to take the medication as he initially
believed that his symptoms may be due to his gall bladder surgery. A week after taking the medication, our client
began to suspect that his medication may be the cause of his quite sudden onset of symptoms. Upon checking the
name of the medication on the box and the enclosed leaflet, on the internet, it was realised that the tablets were for
patients with high blood pressure. He had therefore been dispensed the incorrect medication by the chemist.
Our client highlighted this error to his GP and to the chemist involved who then provided him with the correct
medication and apologised for the serious error that occurred. It took our client months to fully recover from the error
made. Thompsons were successful in representing this client by submitting a claim, obtaining a formal acceptance of
fault from the chemist and finally receiving compensation for the damage caused to the client as a result of the
dispensing error.
Repeat Prescription dispensed incorrectly
Our client, in this case was a gentleman from Wales who attended his GP for a repeat prescription of Amitriptyline of
which he normally took 3 tablets daily. This medication is an anti-depressant. The medication was prescribed and
then collected from his local chemist.
After taking several doses of the medication, our client suffered from a lack of sleep, severe headaches, nausea,
dizziness and a feeling of disorientation. Our client continued to take the medication in the assumption that his
symptoms may be unrelated. Some days after taking the medication, he noticed that the printed label on the
medication box read Amitriptyline but the actual box and the enclosed information leaflet read Amlodipine. This
medication treats patients with high blood pressure and therefore acts to reduce a patients blood pressure.
Our client contacted NHS Direct and was advised to attend his local hospital immediately. Upon attending the
hospital, he was seen by a Cardio-Vascular consultant who explained the seriousness of the incident to our client and
admitted him for 2 days for treatment. Our client was left with continuing symptoms of dizziness and blurred vision
which lasted just under a year.
The error was highlighted to the chemist who acknowledged the error but did not take any further action. Thompsons
successfully represented this gentleman in a Clinical negligence claim against the chemist due to their incorrect
dispensing of medication and obtained an admission of fault from the chemist and compensation for the client after
submitting a claim and obtaining necessary medical evidence on his behalf.

http://www.thompsons.law.co.uk/clinical-negligence/prescription-errors.htm

Dispensing errors wrong medication/wrong strength

Incidents involving pharmacists selecting the wrong medication or the wrong strength are the most common
dispensing errors reported to Guild Insurance. Not surprisingly, a number of these errors involve look-alike, soundalike medications.
Despite awareness raising campaigns, errors still occur. While a person could suffer harm if given any medication in
error, the likelihood of serious clinical effects increases significantly when the medication involved has a narrow
therapeutic index. These errors can and do happen, even to experienced pharmacists whove never made a mistake
before. They can happen to you and they can be fatal to your customers.

Cases

A patient was admitted to hospital with unexplained abdominal bleeding. On investigation he was found to
have an abnormally high INR, even though he had never been prescribed anticoagulant therapy. His elevated INR
was eventually attributed to a dispensing error. The pharmacist had inadvertently made a selection error and
dispensed 5mg Coumadin instead of 5 mg Coversyl as prescribed.

Due to a pharmacists selection error, the cytotoxic medication Hydrea was dispensed instead of the
prescribed antihypertensive Hydopa. The young woman happened to be pregnant and claimed the error resulted in
her suffering a miscarriage.

A customer successfully claimed for loss of income when she was unable to work for an extended period
after a dispensing error. Although the customer had been prescribed Lamictal 25mg, the pharmacist inadvertently
dispensed 200mg tablets. The customer subsequently took the higher dose for a number of months and suffered liver
damage. While the pharmacist said she usually used barcode scanning, she failed to do so on this occasion.

Reduce the risk of dispensing errors

Use barcode scanning every time.

Make use of the safety features available in your dispensing software. Set up different alerts to remind
people to perform certain tasks. Likewise, make use of advanced scanning features that automatically print a
barcode on the dispensing label.

Introduce measures to differentiate between look-alike or sound-alike medications:

Use separators, stickers or flags

Avoid positioning these medications in strict alphabetical order. For example, storing Coumadin under W for
Warfarin, limits the chance of inadvertently selecting Coumadin instead of Coversyl which has similar packaging.
Consider storing other high risk medications separately.

Adhere to the PDL Guide to good dispensing every time. When errors occur, pharmacists often say if only
Id taken the time to. Dont be coerced into rushing or cutting corners.

Promote a culture where all staff are confident to point out risky practices when they occur.

Seek help if you are feeling intimidated or uneasy about contacting the prescriber to clarify a script.

Be careful with zeros and abbreviations. Transcription or interpretation errors involving a zero, decimal point
or abbreviation are common causes of serious dispensing errors. For example 6U of insulin could easily be
interpreted as 60 units.

Reducing distractions when a pharmacist is dispensing is everyones responsibility. Agree strict rules for
minimising interruptions and distractions in your pharmacy.

Review the dispensary layout to ensure workflow supports each step of good dispensing.

When handing medications to a customer, point out all warnings and directions on the label and packaging.
This not only helps with counselling, but serves as a final check against any dispensing error.

http://www.riskequip.com.au/pharmacy/case-studies/dispensing-errors-wrong-medication-wrongstrength

Dispensing errors wrong quantity of medication

A growing number of dispensing errors involving the wrong quantity are reported to Guild Insurance. These
errors occur when a pharmacist dispenses a quantity of medication that differs to the amount prescribed. For
example, the doctor prescribed ten (10) diazepam tablets, but the pharmacist dispensed fifty (50) in error.
While over supply of a medication can cause serious clinical effects, under supply can be equally problematic.
These errors can and do happen, even to experienced pharmacists whove never made a mistake before.
They can happen to you and they can have serious consequences for you and your customers.
Furthermore, in 2012 Guild Insurance received an unprecedented number of claims involving allegations of
unprofessional conduct against pharmacists. Consumers are increasingly intolerant of mistakes and often
object to the way in which the pharmacist handled their complaint. The importance of good communication
cannot be overstated. Pharmacists are urged to undertake regular training in communication and complaints
management.

Case

A woman was prescribed a two week course of Ciprofloxacin 500mg to treat a chest infection.
However, the pharmacist only dispensed a one week supply by mistake. The woman claimed she developed
pneumonia as a result of the pharmacists error.

Reduce the risk of dispensing errors

Adhere to the PDL Guide to good dispensing every time. When errors occur, pharmacists often say if
only Id taken the time to . Dont be coerced into rushing or cutting corners.

Seek help if you are feeling intimidated or uneasy about contacting the prescriber to clarify a script.

Display posters or reminders in the dispensary to promote compliance with dispensing procedures.
Orientate all new staff and locums to these procedures.

Use barcode scanning every time.

Make use of the safety features available in your dispensing software. Set up different alerts to remind
people to perform certain tasks. Likewise, make use of advanced scanning features that automatically print a
barcode on the dispensing label.

Be careful with zeros and abbreviations. Transcription or interpretation errors involving a zero, decimal
point or abbreviation are common causes of serious dispensing errors.

Consider placing flags or warnings in the dispensing basket when handling a script for an unusual
quantity of medication. For example, a simple card statingRISK WARNING different quantity could reduce
the chance of you automatically selecting a standard quantity.

Review the dispensary layout to ensure workflow supports each step of good dispensing.

When handing medications to a customer, point out all warnings and directions on the label and
packaging. This not only helps with counselling, but serves as a final check against any dispensing error.

Reducing distractions when a pharmacist is dispensing is everyones responsibility. Agree to strict

rules for minimising interruptions and distractions in your pharmacy.

Promote a culture where all staff are confident to point out risky practices when they occur.

http://www.riskequip.com.au/pharmacy/case-studies/dispensing-errors-wrong-quantity-of-medication

Dispensing Error Following Childbirth - Compensation

Claim
Naomi, 27 years old, Plymouth
Naomi had an emergency Caesarean Section because of pre-eclampsia. Following delivery
she was inadvertently administered suxamethonium, a paralysing agent used in
anaesthesia, instead of syntometrine, a drug used to cause the uterus to contract. She was
unable to speak or move and lapsed into unconsciousness while trying desperately to
breathe.
Following resuscitation Naomi was transferred to the High Dependency Unit where she
suffered a severe post partum haemorrhage.
She was discharged home 6 days post delivery and soon began to experience symptoms of
post traumatic stress disorder such as nightmares, flash backs, sleep disturbance. She also
had an excessive fear of becoming pregnant again. These symptoms diminished over time
and have now largely resolved apart from a residual fear of becoming pregnant again, it is
hoped that with appropriate cognitive behavioural therapy this will also resolve.
JMW Solicitors were successful in securing Naomi 13,000 compensation when the claim
was settled.
http://www.jmw.co.uk/services-for-you/clinical-negligence/drug-claims/success-stories/dispensingerror/