DISPENSING ERROR
NO
WINNERS in dispensing error case
AS TwO Of PhARmACy’S PROfESSIONAl BODIES APPEAl TO ThE REBAlANCINg BOARD TO ADOPT A PATIENT SAfETy ‘PlEDgE’, NI’S PhARmACy REgUlATOR RUlES ON ThE mARTIN whITE CASE…
T
he Pharmaceutical Society of Northern Ireland’s (PSNI) statutory committee’s hearing
of the martin white case was brought to an end at the end of September, with the committee handing down a seven-month suspension to allow the pharmacist ‘sufficient time to consider the reasoning of the Committee’ while, at the same time, ‘ensuring that the public interest was protected’.
The hearing was the final step in the tragic events of february 6, 2014, when martin white, who was based at Clear Pharmacy in Antrim health Centre, made a dispensing error, which led to the death of patient, Ethna walsh (referred to during the hearing as ‘Patient A’).
On the day in question, mrs walsh’s husband had taken his wife’s prescription for 40 Prednisolone 5mg tablets to the pharmacy, where it was filled by martin white, who was the responsible pharmacist on
8 - PhARmACy IN fOCUS
the day. Unfortunately, by his own admission, martin mistakenly picked up Propranolol instead of the prescribed drug.
PSNI heard that martin white ‘must have mistakenly picked up’ the Propanolol, which was, he stated, ‘side by side’ with the Prednisolone on the shelf.
The regulator stated that there was evidence that ‘Propanolol and the correct medication had been arranged alphabetically in the dispensary, with no warnings in place to differentiate one from another’. however, the pharmacy’s SOPs contained an explicit requirement for the ‘medication (to be) finally checked by a second person’. This had, however, only been introduced ‘a few days before’ the incident, with the pharmacy’s superintendent confirming that there would have been ‘insufficient time to implement the new SOPs before the picking error occurred’.
As a result of the error, mrs walsh, who was aged 67 and suffered from COPD, took eight tablets and ‘quickly fell ill’, PSNI heard. She was subsequently taken to Antrim Area hospital, where she died ‘a short time later’.
In December of last year, martin white was found guilty of ‘supplying a medicinal product in pursuance of a prescription given by a practitioner, which was not of the nature or quality specified in the prescription’.
As a result, he was sentenced to four months’ imprisonment, which was suspended for two years. In this hearing, the regulator alleged impairment on two statutory grounds, namely, misconduct and criminal conviction.
There was no evidence, the Committee found, that martin white had acted in a ‘deliberate, reckless or wilful fashion when he dispensed the wrong medication’. he had, however,
been, the regulator said, ‘completely open and honest in accepting…that he had been responsible for incorrectly dispensing Propanolol against Patient A’s prescription’.
At a time when the pharmacy profession is under increasing pressure due to shortages of both qualified personnel and product, the Committee acknowledged that, while dispensing errors ‘can occur in a busy pharmacy practice’, such errors of the sort under consideration were ‘easily remediable’, concluding that ‘robust personal training and reflection by a pharmacist to learn the lessons caused as a result of the error and supports put in place by an employer could be devised to avoid repetition’.
In its ruling, the regulator acknowledged that while martin had had an ‘unblemished career’ and had been ‘open and transparent’ throughout the investigation, he had not provided any ‘meaningful evidence concerning
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