Pharmacist Issued Warning After High-Risk Dispensing Error involving Methotrexate and Dexamethasone
Date of Decision: March 20, 2025
Registrant's Role: Pharmacist
Allegations:
- Dispensing Methotrexate 2.5mg daily instead of the prescribed Dexamethasone 2mg daily.
- Failing to notice warnings and discrepancies on the medication packaging.
- Inadequate clinical and accuracy checks prior to dispensing.
Outcome: Formal warning issued
GPhC Standards Breached:
- Standard 1 – Provide person-centred care
- Standard 2 – Work in partnership with others
- Standard 4 – Maintain, develop and use professional knowledge and skills
- Standard 5 – Use professional judgment
Case Summary
On 11 May 2023, the registrant was working as the Responsible Pharmacist and failed to correctly check a prescription intended for Patient A. The prescription was for Dexamethasone 2mg daily, but Methotrexate 2.5mg daily—a high-risk immunosuppressant—was dispensed in error.
Despite the medication box displaying clear warnings and significant differences in dose and frequency, the registrant:
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