Pharmacist Issued Warning After High-Risk Dispensing Error involving Methotrexate and Dexamethasone

On 11 May 2023, the registrant was working as the Responsible Pharmacist and failed to correctly check a prescription intended for Patient A. The prescription was for Dexamethasone 2mg daily, but Methotrexate 2.5mg daily—a high-risk immunosuppressant—was dispensed in error.

Despite the medication box displaying clear warnings and significant differences in dose and frequency, the registrant:

• Missed multiple clinical indicators that the medicine was incorrect.
• Failed to conduct a sufficiently careful final accuracy check before the medicine was handed out.

The GPhC found that the error resulted in harm to the patient’s wellbeing, although the exact nature or extent of the harm was not specified.

Findings

The GPhC Investigating Committee concluded that:

• The registrant breached professional standards by failing to deliver safe, person-centred care.
• The error reflected a lack of diligence in applying clinical knowledge and poor use of professional judgment.
• The impact of the error negatively affected the patient’s quality of life.

A direct quote from the committee’s determination emphasised the seriousness of the issue:

“The unavoidable conclusion is that the registrant failed to conduct a sufficiently careful accuracy check.”

The committee did not find the registrant’s fitness to practise impaired, but concluded that a formal warning was required due to the risk to patient safety and damage to public confidence.

Sanction

The Investigating Committee issued a formal warning, which:

• Will be published on the GPhC register for 12 months.
• Acts as a public reminder of the need for accuracy and diligence in dispensing processes.
• Warns that any similar failings in the future may result in more serious regulatory intervention.

The registrant was specifically warned to:

• Ensure all clinical and accuracy checks are completed to a high standard.
• Recognise the impact that dispensing errors have on patient safety and public trust.

Key Learning Points for Pharmacy Professionals

1. Accuracy checks are a critical safeguard – Pharmacists must apply clinical knowledge and check all prescriptions carefully, especially when dealing with high-risk medications.
2. Mistakes involving medicines like Methotrexate can be harmful – The consequences of dosage errors with potent drugs are significant and must be treated with utmost care.
3. Professional judgment must be exercised diligently – Pharmacists are accountable for the medicines they dispense and for catching errors before they reach patients.
4. Dispensing errors undermine public confidence – Even in the absence of intentional wrongdoing, failure to meet standards can result in public regulatory action.
5. Warnings serve as both guidance and deterrent – This formal warning serves as a reminder to the wider profession about the importance of safe practice.

Conclusion

This case demonstrates the serious implications of dispensing errors involving high-risk medication. Although the registrant showed no intentional wrongdoing, the failure to carry out a careful accuracy check led to patient harm and a formal warning. The GPhC’s response reinforces the expectation that every pharmacist must uphold the highest standards of patient care and professional diligence.