Pharmacy Technician Issued Warning for Failing to Escalate High-Risk Medication Concerns

The General Pharmaceutical Council (GPhC) Investigating Committee reviewed the conduct of the registrant between June 2022 and March 2023, during which concerns were raised regarding patient safety risks linked to high-risk medication handling.

At the time, the registrant’s role involved:

• Reconciling medications post-hospital discharge to ensure patients received appropriate treatment.
• Liaising with GPs, pharmacists, and patients to address any issues with medication changes.
• Escalating concerns regarding high-risk medicines to a pharmacist or GP, in line with standard procedures.

However, the GPhC found that the registrant:

• Failed to carry out adequate monitoring for patients on high-risk medication, such as anticoagulants or steroids.
• Did not escalate concerns appropriately, despite employer protocols requiring such cases to be referred to a pharmacist or GP.
• Attempted to modify prescriptions without adequate consultation, exceeding their professional scope.

Findings

The committee determined that:

• The registrant’s actions posed a potential risk to patient safety, although no actual harm occurred.
• Failing to escalate complex medication cases undermined safe prescribing practices.
• The registrant accepted responsibility, acknowledged their errors, and took steps to revise their approach to practice.
• Contextual factors, including workplace pressures, management changes, and personal health issues, contributed to the failings but did not excuse them.

A direct quote from the ruling emphasized the significance of the warning:

“A warning is required to stand as a reminder that the registrant must ensure they act within their legal and professional obligations, including their scope of practice, and only practise when fit to do so.”

GPhC Determination on Impairment

The committee concluded that the registrant’s fitness to practise was not impaired, as they had:

• Demonstrated reflection and learning from the investigation.
• Revised their clinical decision-making approach.
• Acknowledged the importance of staying within their professional boundaries.

However, the GPhC determined that a formal warning was necessary to:

• Serve as a reminder of professional responsibilities.
• Ensure public confidence in the pharmacy profession.
• Act as a deterrent against future breaches.

Sanction

The committee issued a formal warning, which:

• Will be published on the GPhC register for 12 months.
• Acts as a public declaration that the conduct was unacceptable.
• Warns that any repetition may result in further regulatory action.

Key Learning Points for Pharmacy Professionals

1. High-risk medicines require enhanced monitoring – Failure to properly assess and escalate concerns can lead to patient harm and regulatory action.
2. Pharmacy technicians must work within their professional scope – Modifying prescriptions without consultation is outside the responsibilities of a pharmacy technician.
3. Escalation protocols must be followed – Concerns regarding anticoagulants, steroids, and other high-risk medicines must be referred to a pharmacist or GP.
4. Workplace pressures do not remove professional accountability – The registrant’s workload and management issues contributed to the errors but did not excuse them.
5. Warnings remain on the public register – Any future misconduct may result in more serious sanctions.

Conclusion

This case highlights the critical importance of recognising professional limitations and following escalation procedures. While the registrant took appropriate remedial steps, their failure to properly manage high-risk medication cases warranted a formal warning. The warning serves as a reminder that all pharmacy professionals must operate within their scope of practice and prioritise patient safety at all times.