Warning Issued for Failure to Ensure Safe Dispensing of Anticoagulants by Responsible Pharmacist

Date of Decision: July 3, 2025

Registrant's Role: Pharmacist

Allegations:

Failure to ensure the safe dispensing of high-risk medication.
Inadequate clinical checks for a patient prescribed two anticoagulants.
Breach of responsibility as the Responsible Pharmacist.

Outcome: Warning issued

GPhC Standards Breached:

Standard 1 – Provide person-centred care, considering the impact of decisions on people.
Standard 2 – Work in partnership with others to ensure continuity of care.
Standard 3 – Communicate effectively with those involved in the person’s care.
Standard 5 – Use professional judgement to make appropriate clinical and professional decisions.

Case Summary

Allegations

The case centres on a serious lapse in clinical oversight by the registrant, who was the Responsible Pharmacist (RP) at a retail pharmacy in Weybridge on 2 October 2020. The RP failed to adequately ensure the safe and appropriate dispensing of high-risk medication—specifically, two different anticoagulant drugs prescribed simultaneously to a single patient. Anticoagulants are high-alert medications with a known risk of causing significant harm if used inappropriately, particularly when duplicated or combined in error.

As RP, the registrant held ultimate accountability for the pharmacy’s safe operation during their shift. The core allegation relates to their failure to conduct necessary clinical checks that could have prevented the dispensing of two anticoagulants, a clear contraindication that posed a potential risk of serious harm.

Findings

The Investigating Committee found that the registrant did not meet the necessary standard of care in their role as RP. They were responsible for ensuring that all prescriptions dispensed were clinically appropriate and safe for the patient. The committee considered it a serious failure in professional duties that the registrant failed to question or investigate the dual anticoagulant therapy before supply.

Such an oversight not only endangered patient safety but also reflected poorly on the professional standards expected of a pharmacist acting as RP. The pharmacy professional should have ensured that all necessary patient information was obtained and carefully reviewed. Had this been done, the error could likely have been caught and corrected.

GPhC Determination on Impairment

The panel did not find the registrant’s fitness to practise to be currently impaired to the extent that more severe sanctions, such as suspension, were warranted. However, they did determine that the nature of the registrant’s conduct justified formal regulatory attention in the form of a warning. The committee expressed concern that the actions breached several key GPhC Standards for Pharmacy Professionals, which uphold patient safety, collaborative care, effective communication, and clinical judgment.

“[The registrant]’s failures and breach of standards have the potential to cause a risk of serious harm to members of the public. Public confidence in the pharmacy profession is also undermined by such failures.”

They highlighted the need for enhanced vigilance in prescribing checks, especially when it concerns medications with a narrow therapeutic index like anticoagulants.

Sanction

The outcome of this case was a formal warning, to remain on the registrant’s record and public profile for a period of 12 months. The committee considered this appropriate due to the serious risk of harm created by the registrant’s conduct, while acknowledging the context and likely lack of intent.

The warning included a direct expectation that the registrant “must obtain all necessary patient information before supplying medication and be alert to potential contra-indications and interactions.” It also stressed that repetition of such failings could result in more serious regulatory consequences.

Key Learning Points for Pharmacy Professionals

Anticoagulant Safety is Paramount: Pharmacists must exercise extreme caution with high-risk medications like anticoagulants. Double dispensing of such drugs can cause significant adverse effects, including increased risk of internal bleeding.
Responsible Pharmacist Accountability: Being designated as the RP entails a legal and professional obligation to oversee all dispensing activities. This includes challenging or clarifying prescriptions that may seem clinically inappropriate.
Clinical Checks Must Be Robust: Even if prescriptions appear valid, a lack of adequate clinical checking—especially in elderly or high-risk patients—can lead to harmful errors. Pharmacists should always verify the indication, dosing, and potential interactions.
Communication and Collaboration are Critical: Pharmacists must proactively communicate with prescribers or other healthcare professionals when concerns arise. Doing so helps maintain the integrity and safety of the patient’s care pathway.
Regulatory Oversight Can Be Triggered by One Error: Even a single clinical lapse, if it poses a serious risk to patient safety, can prompt an investigation and warning. Professionals must be diligent in all aspects of care, no matter how routine the task may seem.

This case serves as a stark reminder of the diligence required in the responsible supply of medications. Pharmacists are encouraged to maintain a questioning attitude, especially when faced with potentially hazardous drug combinations, and to never assume the accuracy of prescriptions at face value.

Original Case Document

The full determination transcript is available to logged in users.