Colchicine Dispensing Error Leads to GPhC Warning for Retail Pharmacist

Date of Decision: September 18, 2025

Registrant's Role: Pharmacist

Allegations:

• Dispensing Colchicine 500mcg tablets with incorrect dosage/frequency instructions.
• Failure to provide patient counselling.
• Failure to supply a patient information leaflet with the medication.

Outcome: Warning issued by the GPhC Investigating Committee.

GPhC Standards Breached:

• Standard 1 – Pharmacy professionals must provide person-centred care.
• Standard 3 – Pharmacy professionals must communicate effectively.

Case Summary

Allegations

The case centres around a significant dispensing error made by the registrant while acting as the Responsible Pharmacist in a retail pharmacy in Harlow on 26 January 2025. The medication in question was Colchicine 500mcg tablets, a drug with a narrow therapeutic index, commonly used to treat acute gout and familial Mediterranean fever. The registrant erroneously supplied 12 tablets to a patient (Patient A) with dosage instructions that would have resulted in double the prescribed daily dose. Compounding this issue, the medication was dispensed without any accompanying counselling and no patient information leaflet was included in the supply.

These combined errors posed a serious risk of patient harm. Colchicine, in excessive doses, can lead to toxicity, necessitating emergency medical intervention. Had the patient followed the dosage instructions as labeled, it is likely they would have had to attend A&E, illustrating the gravity of the error.

Findings

The GPhC Investigating Committee determined that the registrant’s conduct breached multiple professional standards, specifically:

• Standard 1, which requires pharmacy professionals to provide person-centred care by sharing relevant information and using the best resources available.
• Standard 3, which pertains to effective communication with patients.

The Committee noted the absence of any patient interaction or counselling, as well as the missing patient information leaflet, as clear breaches of expected professional behaviour. These failings significantly compromised patient safety.

GPhC Determination on Impairment

Although this was not a full Fitness to Practise hearing but rather an assessment by the Investigating Committee, the GPhC clearly found the registrant’s actions to have serious implications for public safety and trust in the profession. The potential for harm was substantial, especially considering the pharmacological profile of Colchicine. The Committee emphasized that pharmacists must undertake thorough accuracy checks and adhere to a person-centred approach to care in order to ensure medication safety.

“The purpose of the warning is to remind [the registrant] of the need to abide by all GPhC standards and ensure that he conducts careful accuracy checks before dispensing medication and adopt a person-centred approach in order to provide safe and effective patient care and minimise any risk of errors.”

Sanction

A formal warning was issued. The warning is to be published on the GPhC register for 12 months. The Committee opted for this outcome as the most appropriate, signalling that while this incident did not yet rise to the level requiring suspension or conditions, it did warrant a public regulatory response.

The warning serves as both a reprimand and a preventative intervention, cautioning the registrant that any repetition of such conduct would likely lead to further, and potentially more severe, regulatory consequences.

Key Learning Points for Pharmacy Professionals

1. Accuracy Checks are Critical – Especially when dealing with medications that have a narrow therapeutic index like Colchicine, a minor dosing error can lead to major clinical consequences. Double-checking labelling, directions for use, and quantities must be standard practice.
2. Patient Counselling is Mandatory – Regardless of workload or time constraints, counselling must never be omitted, especially with drugs where dosage compliance is crucial for safety.
3. Provision of Information Leaflets is a Legal and Ethical Requirement – Patient information leaflets are not optional extras. They are fundamental to informed patient care and should accompany all dispensed medication unless explicitly declined.
4. Effective Communication Prevents Harm – The absence of both verbal counselling and written instructions significantly increases the risk of misuse. Pharmacists must communicate clearly and proactively.
5. Warnings are Serious Regulatory Actions – While not as severe as suspension or removal, a warning is a public mark on a professional’s record. It signifies a lapse that, if repeated, could escalate to a Fitness to Practise case.

This case underlines the non-negotiable importance of vigilance in dispensing practice, especially with high-risk medications. Pharmacists must remain consistently attentive to detail and committed to the standards that protect patients and uphold the integrity of the profession.

Original Case Document

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