Extemporaneous Dispensing Errors in a Paediatric Cardiology Patient: Lessons in SOP Compliance and Professional Insight
Date of Decision: June 24, 2013
Registrant's Role: Pharmacist
Allegations:
- On 12 December 2011 at Four Winds Pharmacy, the registrant dispensed:
- (i) Captopril Oral Solution 5 mg/ml TID (three times daily), and
- (ii) Furosemide Oral Suspension 20 mg/5 ml, 100 ml, 4.5 mls twice daily,
- in circumstances corresponding to a retail sale, in contravention of section 58(2)(a) of the Medicines Act 1968, in that the medicinal products supplied were not of the nature or quality demanded by the purchaser, contrary to section 64(1) of the Medicines Act 1968.
- The registrant failed to:
- (a) recognise the dispensing errors when concerns were raised by Miss B;
- (b) take the opportunity to remediate the dispensing errors when concerns were raised;
- (c) follow standard operating procedures in relation to extemporaneous preparations;
- (d) complete, properly or at all, extemporaneous dispensing worksheets;
- (e) exercise a sufficient level of supervision over subordinate staff;
- (f) properly and accurately check the dispensing label against the prescription;
- (g) deal properly with a complaint raised by Mr B on 13 January 2011.
- By these acts and omissions, the registrant created a clear risk to the safety of Patient A.
Outcome: The Committee determined that the registrant’s fitness to practise was not currently impaired. No warning was imposed.
GPhC Standards Breached:
- Standard 1 – Make the safety and welfare of patients your prime concern
- Standard 4 – Exercise professional judgment in the interests of patients and the public
- Standard 6 – Maintain and develop professional knowledge and competence
- Standard 7 – Act with honesty and integrity
- Standard 8 – Provide a high standard of practice and care at all times
Case Summary
Allegations
This case concerned admitted misconduct arising from dispensing errors involving two cardiovascular medicines supplied to a highly vulnerable paediatric patient. The patient, aged two months at the time, suffered from complex congenital heart disease. The medicines involved were captopril oral solution 5 mg/ml (to be administered three times daily) and furosemide oral suspension 20 mg/5 ml, with a prescribed dose of 4.5 mls twice daily.
Both medicines are clinically significant in the management of paediatric heart failure. Captopril, an ACE inhibitor, reduces afterload and improves cardiac output, but carries risks of hypotension, renal impairment and electrolyte disturbance. Furosemide, a loop diuretic, is essential for managing fluid overload but requires precise dosing to avoid dehydration, electrolyte imbalance, or worsening renal function. In neonates and infants, even minor dosing inaccuracies can have profound physiological consequences.
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- Full allegations considered by the GPhC
- Panel findings and reasoning
- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
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