Pharmacist Given 12-Month Conditional Registration After Multiple Dispensing Errors and Patient Harm
Date of Decision: November 3, 2020
Registrant's Role: Pharmacist
Allegations:
- Made multiple dispensing errors, including wrong medications and incorrect dosages.
- Allowed pharmacy students and trainees to handle dispensing without proper supervision.
- Failed to carry out final accuracy checks, including for high-risk medications.
- Errors led to moderate harm, including a hospital admission and physical injury to a patient.
- Continued to make errors despite previous warnings and advice from GPhC.
Outcome: 12-month conditional registration
GPhC Standards Breached:
- Standard 1 (2012) – Make patients your first concern
- Standard 2 (2017) – Work in partnership with others
- Standard 5 (2012 & 2017) – Use professional judgment
- Standard 7 (2012) – Take responsibility for your working practices
- Standard 9 (2017) – Demonstrate leadership
Case Summary
The registrant admitted to a series of six dispensing errors between 2018 and 2019 while working as a pharmacist and pharmacy owner. The errors included:
- Supplying Bisoprolol instead of Bendroflumethiazide
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- Full allegations considered by the GPhC
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- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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The original determination transcript is available to registered users.
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- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
- Details of the pharmacy professionals involved