DISPENSING ERROR


his insight and the steps he would take to ensure’ that a similar error would not be repeated.


The Committee stated, however, that it was not ‘persuaded that mr white’s actions, while serious, were fundamentally incompatible with continued registration or that public confidence in the pharmacy profession would be undermined by the imposition of a less restrictive sanction, in this case suspension’, it considered that, ‘at this stage, striking-off would be a disproportionate sanction to apply’.


Both points were rather moot in light of the fact that, although he did not attend the hearing, martin white had categorically stated that he ‘found it impossible to conceive that he could practise again’.


The ruling came just as two of pharmacy’s professional bodies - the Pharmacists’ Defence Association (PDA) and the National Pharmacy Association (NPA) issued an appeal to the Department of health’s (Doh) Rebalancing Board to adopt a patient safety ‘pledge’ in light of growing concerns about a relaxation of pharmacist supervision of medicines supply.


In february 2015, the Doh issued a consultation document, which focused on decriminalising dispensing errors by providing pharmacists with a defence against criminal sanctions for dispensing errors made ‘inadvertently’. while the Rebalancing Board did publish a report in february of last year, detailing the responses to the consultation, it also stated that a ‘separate report’ would be published on the responses to the consultation questions on the Pharmacy (Preparation and Dispensing Errors) Order 2016, it gave no indication of when this would happen and, to date, nothing has been forthcoming.


Any future ruling will, however, be of little interest to martin white, who, from the outset, the Committee ruled, had been open and transparent in connection with the investigation into the cause of mrs walsh’s death.


‘he had,’ the Committee stated, ‘accepted the significance of his role in dispensing the incorrect medication to Patient A (mrs walsh) and had pleaded guilty in the criminal proceedings brought against him in


respect of his error. he had also, through his legal representatives, made wholescale admissions at the outset of these proceedings. There was also some evidence that, to a limited degree, mr white had insight into his failings. for these reasons, while it could be said that mr white’s actions were serious and had profound consequences, they could not properly be described in themselves, as being fundamentally incompatible with continued registration as a pharmacist.’


In response to the Committee’s ruling, NI’s leading pharmacy bodies were cogniscent of the tragic consequences for all concerned.


‘This case,’ Pharmacy forum NI said in a statement, ‘is a tragedy, first and foremost for Ethna walsh and her family, who have lost a wife, mother and grandmother. for martin white, a pharmacist who up to this point had an unblemished career, there are


honest culture that encourages the reporting of errors and the ability to learn from them. It is our view that the current work on rebalancing legislation and regulation, with which the Pharmacy forum NI is involved, will ensure that future legislation will promote and strengthen this culture in the context of professional accountability.


‘we continue to strive to eliminate error and the source of errors throughout the dispensing process, from the clinical appropriateness of the medicine, strength and dose through to the assembly of product and patient counselling. we do this in many settings in both primary and secondary care. while it has become trite to say that ‘lessons will be learned’, it is nonetheless essential that they are and, in that context, important learning has already been cascaded to the profession through the initial investigation of this serious incident and that will continue now,


‘While incidents of this kind are thankfully rare, they illustrate


precisely why the profession is and remains focused on prioritising patient safety at all times’


the devastating consequences of an unintentional act. while incidents of this kind are thankfully rare, they illustrate precisely why the profession is and remains focused on prioritising patient safety at all times. with over 40 million prescription items dispensed in Northern Ireland pharmacies every year and nine per cent of the population visiting a pharmacy every day, it is vital that the relationship of trust is maintained.


‘As the professional leadership body for pharmacists in Northern Ireland, a central component of our work is ensuring that pharmacists are fully trained and supported to deliver the highest quality services to the public.


As healthcare professionals, pharmacists recognise that we must be accountable for our actions and accept responsibility when things go wrong. Indeed we are currently the only health care professionals who commit a criminal offence if an inadvertent error occurs. going forward, we must have an open and


after this regulatory determination, to ensure that we as a profession, along with other key stakeholders do all we can to prevent this happening again in the future.’


The Ulster Chemists’ Association (UCA), meanwhile, viewed the case as an opportunity for steps to be put in place to ensure that such a tragedy does not occur again.


‘The Pharmaceutical Society’s determination on the case of martin white,’ said UCA President, Cliff mcElhinney, ‘is to be welcomed in light of the move towards decriminalising accidental dispensing errors. mr white’s suspension from the register can be seen as a fair outcome, whilst the pharmacist in question has indicated to the Society that he does not intend to return to practice. There can certainly be no ‘good’ outcome for either mrs walsh’s family or martin white and all that can be hoped for is some insight into what went wrong with a view to reducing the risk of a recurrence.’


Cliff McElhinney, President, Ulster Chemists' Association


Cliff’s words were echoed by those of gerard greene, Chief Executive of Community Pharmacy Northern Ireland.


‘This is a tragic case for all involved,’ he said, ‘but, in particular, for the family and friends of Ethna walsh. An inadvertent dispensing error resulted in mrs walsh’s death and her passing will undoubtedly continue to have a huge impact on those close to her.


‘for martin white, the consequence of that dispensing error will also have had a devastating impact, as will having to go through the subsequent legal and Statutory Committee processes. No pharmacist ever wants to be responsible for dispensing errors of any kind and for martin white the work being undertaken by the Rebalancing Board to look at decriminalising inadvertent dispensing errors is too late.


‘whether the rebalancing work ever results in the decriminalisation of inadvertent dispensing errors or simply goes as far as providing a statutory defence in instances of inadvertent dispensing errors remains to be seen.


‘for the profession, and especially those in community pharmacy, the outworking of the Rebalancing Board is critical and many within the sector will want to see that it fully addresses the huge anomaly that currently exists around dispensing errors.’


The martin white case sent shock waves throughout NI pharmacy and brought home to community pharmacy - if any reminder was actually needed - the stark - and tragic - consequences of a simple dispensing error.


PhARmACy IN fOCUS - 9


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48