OPINION


ERROR H


DISPENSING By Terry Maguire


is demeanour was that of a victim – complete with police escort - approaching the scene


of the crime and the suspect still in place. He curtly asked to speak to the pharmacist. In each hand he held a box of medicines and, as I approached, he reached them out towards me, stating assertively that he had been dispensed these medicines on the 12th of the month to treat a fungal infection.


It was now the 28th and, he asserted, he had been taking them for two weeks and they were the wrong medicines. He had just come from the GP who was ‘shocked and disgusted’ that we had made such a serious mistake. He was, he said, ‘unwell, tired, yawning a lot’ and he had a ‘body rash’.


The GP, he continued, while staring at the boxes, was referring him to a more senior doctor and the practice was investigating what side-effects he might be suffering from now, and may possibly suffer from in the future. He had to go back later to have bloods taken.


It was first thing on a Monday morning and I found my mouth


drying, my stomach becoming heavy and my heart beginning to race. The medicine in his right hand was Lamotrigine 200mg and the one in his left Sertraline 100 mg; each to be taken once daily. I asked cautiously if I could see the boxes and he reluctantly handed them over, keeping a keen eye for sleight of hand. They were indeed dispensed at our pharmacy on the 12th and they were not for a fungal infection I told him. I asked if the name on the medicine labels was his own and he confirmed it was.


I apologised and offered to get to the bottom of how this could have happened. I explained that I would take full responsibility and that I was reassured he had seen the GP and was getting medical attention. I explained the nature of the medicine: one was for epilepsy and the other for depression. He interjected that he did not have either of these conditions and that he was concerned with the long-term consequences. I assured him that these were widely- used medicines and that the side-effects he described were common and not serious.


Once he stopped using them, there were unlikely to be any long-term consequences. I also explained that


I accepted that a serious error had occurred and I was telling him about the side-effects merely to reassure him, not to mitigate the error. For the first time, we had eye contact, but he quickly turned his attention back to the boxes.


I explained what would happen. I would get the prescription but it wasn’t in the dispensary. It had been submitted on the Friday for pricing and so I would need to retrieve it. Hopefully the pricing department could confirm in a few hours what was on the prescription and I would come back to him with a clear explanation.


At that moment, the patient’s mobile phone rang in his jacket pocket and I offered him the opportunity to answer it. He declined. before I returned to the dispensary to record his details in the day book and find the PMR, he insisted that he got the boxes back. I handed them over.


The PMR told me he was a new patient and that the prescription was scanned. I confirmed his name, but the address on the PMR was different. I felt relief, but said nothing. He then left.


I rang the pricing department, but they had not yet scanned the


prescriptions and said that it would be a few days perhaps before they could locate it. I was about to ring the GP when the GP actually telephoned me. Hands up, he said, explaining that it was their fault. The GP explained that they had two patients with the same name and asked if we had the prescription for the anti- fungal medicine.


I was overcome with feelings of both oozing relief and giddy joy. I told the GP I had done what I could to reassure the patient about long- term consequences. He admitted that, when they had established what had happened, they had tried to ring the patient’s mobile to explain before he reached the pharmacy, but he hadn’t answered.


The patient had now insisted on having bloods done and they were currently doing this. I could have suggested that they might perhaps not be so quick to tell a patient how ‘shocked and disgusted’ they were while implicating the pharmacist.


but I didn’t.


That was the last I heard of the incident. I didn’t phone the patient back as I’m sure he was much too busy with his solicitor.


PHARMACY IN FOCUS - 27


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