Clarification needed for one-off dispensing errors
From Mr G. W. Watson, MRPharmS
The article on accredited checking technicians (Retail Round-up, September 2008, p1) was interesting, particularly the reference to one of the technicians “making only six errors in four years”.
All humans are fallible, this is probably fairly typical of the error rate in most pharmacies and these are presumably those errors that reached the patients.
Perhaps, in light of the article, the Royal Pharmaceutical Society can have clarification of the policy for referral to the Investigating Committee. The Council has decided that single one-off dispensing errors should not be referred, does this mean one error per working lifetime, no more than one error every 18 months or does it not apply to technicians and their supervising pharmacists at all?
Geoff Watson
Barnard Castle, County Durham
Sarah Billington, Royal Pharmaceutical Society, responds
Sarah Billington, chief inspector, Royal Pharmaceutical Society
The statutory registration of pharmacy technicians is expected in early 2009, once Order 1B to the Pharmacy and Pharmacy Technicians Order 2007 has been laid before Parliament. At the current time, and in the absence of any statutory provisions governing pharmacy technicians, the Society is operating a voluntary register for pharmacy technicians.
As part of the registration process, pharmacy technicians sign up to a voluntary registration protocol that has been approved by the Society’s Council. They also agree to be bound by the Code of Ethics for Pharmacists and Pharmacy Technicians, and to be subject to investigation and be bound by the outcome of a disciplinary committee in cases involving impaired fitness to practise or misconduct. A copy of the current 2008 protocol can be found on the Society’s website.
In the case of an allegation or complaint made to the Society about an accredited checking technician, there are potentially a number of issues. If the pharmacy technician is not on the voluntary register then they do not currently come within the jurisdiction of the Society.
However, those pharmacy technicians that are on the voluntary register would be subject to an investigation and could be removed from that voluntary register should it subsequently be proved that they are unfit to practise or have committed misconduct.
At present, the pharmacy technician voluntary protocol does not include a mechanism to refer technicians to an investigating committee. The protocol simply provides that a fitness to practise allegation will be referred to an interim disciplinary committee.
However, the Society is taking steps to address this so if a fitness to practise issue arises involving a technician they will be dealt with using a procedure that is similar to the statutory system already in place to deal with pharmacists.
In relation to the issue regarding single one-off dispensing errors, the Society’s Council agreed, at its meeting in June 2008, that the threshold criteria should apply to cases involving pharmacists and registered pharmacy technicians.
The Council’s decisions on the threshold criteria and the types of cases suitable for non-referral, including dispensing errors, can be found on the Society’s website.
As to the supervising pharmacist’s role in the case of a dispensing error made by an accredited checking technician, the supervising pharmacist is ultimately responsible for the supply of medicines from the pharmacy. He or she may choose to delegate the dispensing and accuracy checking of prescriptions but that does not absolve him or her of the responsibility.
Accountability is a complex issue and the level of an individual’s accountability can vary depending on the specific circumstances. It is beyond the scope of this response to cover the issue of responsibility and accountability in detail but further information can be obtained from the Society’s website and previously published articles (PJ, 28 February 2004, p261; 3 July 2004, p35; and 6 January 2001, p10).
With regards to the correspondent’s specific query about the non-referral mechanism for a “single one-off dispensing error” and whether this means only one error per lifetime or a specific number of individual errors over a specific period. The short answer is no.
The Council did not consider the number or frequency of “single one-off dispensing errors” as a barrier to any single error being considered as suitable for non-referral. However, it did want to ensure that registrants take notice of any advice given and take steps where possible to prevent further errors.
Therefore, the Council has stated as one of the threshold criteria, that cases are likely to be referred to the Investigating Committee if “the Society had previously given advice that would have prevented the incident if it had been implemented”. Cases are looked at on an individual basis.