Pharmacist Issued Warning After Dispensing Error Leads to Patient’s Accidental Overdose Death
Date of Decision: September 13, 2023
Registrant's Role: Pharmacist
Allegations:
- While working as a locum pharmacist and Responsible Pharmacist at Crompton Pharmacy, Chelmsford, the pharmacist:
- Dispensed 56 tablets of 120mg Oxycodone Hydrochloride instead of the prescribed 56 tablets of 20mg Oxycodone Hydrochloride.
- Supplied the incorrect medication to Patient A, who later suffered an accidental overdose and died.
- Failed to carry out proper checks despite being questioned by a colleague about the medication.
- Did not recognise the need for a second checker when dispensing a controlled drug.
- Attributed the error to fatigue, stress, and working excessive hours in an understaffed pharmacy.
Outcome: Issued a formal warning
GPhC Standards Breached:
- Standard 1 – Provide Person-Centred Care
- Standard 3 – Communicate Effectively
- Standard 5 – Use Professional Judgment
Case Summary
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:
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