Decriminalising Dispensing Errors

There's been a lot in the PJ this year about the almost-there-but-yet-so-far-away decriminalisation of genuine single dispensing errors. I must admit, I've been relatively blind to this until today; in the course of pharmacy law revision, I came across an article on the Daily Mail website^[1] regarding a potentially horrific dispensing error in the USA. It concerns a pregnant woman who was prescribed antibiotics and mistakenly given another patient's medication by the pharmacist when she went to collect them. To make matters worse, the medication she was given was methotrexate, she was six weeks pregnant at the time and she had already taken the drug before noticing the extremely similar name to hers on the medicine label.

Methotrexate, as you probably know, is classed as a pregnancy category X drug by the FDA and should consequently be avoided by pregnant and lactating women at all costs as it has been shown to cause foetal abnormalities.

One can only imagine how much stress this incident must have caused to the patient and the pharmacist. The American media jumped all over it too (not too different to ours then). No-one in their right mind would intentionally dispense a potentially dangerous drug, so would it be fair to prosecute someone for it? Are we not human? Would it not only heap more pressure onto an already stressed individual? It could also be argued that pharmacists, particularly community pharmacists, have just too much to do, what with meeting MUR targets and the tens of public health services that are offered.

On the other hand, someone needs to take responsibility for the mistakes, especially in cases like this where the dispensing error could cost a life; often, prosecution is the step that allows a grieving family to move on with their lives.

When I used to work in a community pharmacy, we always confirmed the addresses of patients to ensure that we were handing the medication to the right patient. This case could easily have been avoided had the pharmacist been following good practice procedures of confirming patient addresses; while there are potentially many cases like this, I'm sure there are equally as many complex cases that genuinely were either unavoidable or a mistake.

So, where does that leave the UK? I'm on the fence but I'm leaning towards decriminalising single dispensing errors and I must admit, I wouldn't want to be one of those involved with making the decision.

Reference:
1. Bazley L. Mother-to-be could lose baby after pharmacist gave her abortion pill by mitake. Mail Online. 08/02/2011 (accessed on 21/12/2011); News. Available at http://www.dailymail.co.uk/news/article-1354777/Mo...