Pharmacist Issued Warning After Dispensing Error Leads to Patient’s Accidental Overdose Death

The General Pharmaceutical Council (GPhC) Fitness to Practise Committee investigated a pharmacist after a dispensing error led to a patient’s accidental overdose and death.

On 11 November 2019, the pharmacist:

1. Mistakenly dispensed Oxycodone 120mg instead of the prescribed 20mg.
2. Labelled and ordered stock for the incorrect strength.
3. Worked in an understaffed pharmacy without a second checker.
4. Did not verify the prescription strength when questioned by a colleague.
5. Supplied the medication to Patient A, who later died from an overdose after taking one tablet.

The error was discovered after the patient’s death, prompting a GPhC investigation.

Findings:

The Fitness to Practise Committee found that the pharmacist’s conduct amounted to serious professional misconduct, considering:

1. Fatal Dispensing Error and Missed Opportunities to Correct It:
   • The pharmacist misread the prescription strength, resulting in a sixfold overdose.
   • Multiple opportunities were missed to identify the error before dispensing.
   • The committee noted:“Had proper checks been conducted, this fatal error could have been avoided.”
2. Failure to Verify the Prescription Despite Being Questioned:
   • A colleague raised concerns about the Oxycodone prescription, but the pharmacist did not check the label or packaging again.
   • The committee found that better communication and a second check could have prevented the fatal mistake.
3. Unsafe Working Conditions Contributed to the Error:
   • The pharmacist worked long hours in an understaffed pharmacy, leading to fatigue and stress.
   • He was covering shifts for a bereaved colleague and was exhausted at the time of dispensing.
   • The committee ruled:“While work pressure and fatigue may have contributed, professional responsibilities remain paramount.”
4. Immediate Admission of Error and Apology:
   • The pharmacist immediately admitted his mistake to the pharmacy and at the coroner’s inquest.
   • He expressed deep remorse and personally apologised to the patient’s family during the inquest.

GPhC Determination on Impairment:

The GPhC ruled that the pharmacist’s fitness to practise was impaired, citing:

• Failure to uphold fundamental pharmacy standards.
• Serious harm caused to a patient as a result of an avoidable error.
• Potential damage to public confidence in pharmacy practice.

The committee stated:

“The registrant’s errors resulted in a patient’s tragic death. While there is no evidence of malicious intent, this case highlights the importance of professional diligence in dispensing.”

However, the committee acknowledged that:

• The pharmacist had an otherwise unblemished 24-year career.
• He had demonstrated full insight into his mistake and taken steps to prevent recurrence.
• He had continued working safely since the incident with no further concerns.

Given these factors, the committee found that:

“While this was a catastrophic error, the registrant does not pose an ongoing risk to public safety.”

Sanction:

The committee issued a formal warning, considering:

• Aggravating Factors:
  • The error resulted in a patient’s death.
  • There were multiple missed opportunities to identify the mistake before dispensing.
  • The pharmacist worked excessive hours, contributing to the error.
• Mitigating Factors:
  • The pharmacist admitted the error immediately.
  • He expressed genuine remorse and personally apologised to the patient’s family.
  • He had no previous disciplinary history in 24 years of practice.
  • He had taken extensive steps to prevent future errors, including additional training and procedural changes.

The committee ruled that:

“A warning is sufficient to uphold public confidence in pharmacy, given the registrant’s insight and remediation.”

A formal warning was recorded on the GPhC register for 12 months, but no suspension or further restrictions were imposed.

Key Learning Points for Pharmacy Professionals:

This case highlights critical lessons regarding safe dispensing, professional judgment, and mitigating dispensing errors.

1. Always Double-Check Prescription Strengths, Especially for Controlled Drugs:
   • Controlled drugs require heightened vigilance due to their potency.
   • Second checks, where possible, should always be performed before dispensing.
2. Workplace Pressures Must Not Compromise Patient Safety:
   • The pharmacist cited fatigue and understaffing as contributing factors to the error.
   • If working conditions compromise safe practice, pharmacists must escalate concerns.
3. Address Concerns Raised by Colleagues Promptly:
   • A colleague questioned the prescription, but the pharmacist did not recheck it.
   • Pharmacists must always take concerns seriously and verify medication details before dispensing.
4. Full Insight and Remorse Can Impact Regulatory Outcomes:
   • The pharmacist avoided suspension due to his immediate admission of error and remediation efforts.
   • Taking proactive steps to prevent future mistakes is key to maintaining professional trust.

Conclusion:

This case serves as a tragic reminder of the critical role pharmacists play in ensuring medication safety.

While the pharmacist avoided suspension, the formal warning underscores the importance of accuracy, professional diligence, and safe working conditions.

Pharmacists must prioritise patient safety at all times, ensuring that dispensing errors are minimised through robust checking procedures and professional judgment.