Dispensing errors can be defined as content errors and/or labeling errors1. These errors generally involve pharmacists dispensing the wrong product to the patient or displaying wrong information on the dispensing label1. Error of medicinal content could mean supplying patient with a different product, strength, form or quantity from the prescription. Displaying the wrong information on the dispensing label could mean different patient’s name, different description of the medication or different dose. These errors can happen at any stage of the dispensing process. However, it is the duty of pharmacists to intercept these errors before it reaches the patient that potentially cause harm or even death. In this essay, I will discuss whether it is fair for pharmacists to face legal action for dispensing errors.
According to analysis done by the Patient Safety Observatory (PSO), they have reported that dispensing error happens in 0.2% of 985 940 items dispensed7 in the community pharmacies and approximately 2.1% of
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4849 items dispensed7 in the hospital pharmacies. Torjesen3 mentioned these low rates in the data show that pharmacists are reporting less in fear of legal action. Although the law of protecting the purchaser has been around since 1968, in the Medicines Act 1968, it was brought into light recently when a locum pharmacist, Elizabeth lee, inadvertently dispensed propranolol instead of prednisolone, which resulted in the death of her patient4. The Medicine Act 1968 protects patients from receiving any medicinal products that they do not require5 (section 64.1) and also protect them from receiving medicinal products that is falsely described5 (section 85.5). The Crown Prosecution Services (CPS) decides if a case is brought to court or dealt with individually8. For more than 40 years, the CPS has not acted until the prosecution of Elizabeth Lee, which shocked the nation. This shows that pharmacists are not aware of such ruling until lee’s incident, therefore responding for a change the Medicines Act. Although pharmacy dispensing has not changed over the decade, the number of prescriptions and the demands pharmacists require to meet has increased by more than times since the 1960s8. Pharmacists are the only healthcare professionals that risk legal charges and prosecution threat for making an honest mistake4.
This approach is not fair as 24.1% of the dispensing errors encountered in the pharmacies are reported to be prescribing errors7. But prescribers are not criminalized for their errors. For an instance, the General Medical Council (GMC) recently struck off junior doctor, Dr. Pillay, after overdosing two of his patients and several misconduct9. However, there were no records of Dr. Pillay being legally charged for death he caused due to his prescribing error. Lee, on the other hand, had seven years experience, made one inadvertent error, was sentence to three-month suspended jail sentence. Her sentence was later reduced to a fine of £3003. Both health care professional are responsible for the health and well being of their patients. Jeopardizing their safety due to human error should not be punishable to only one professional but
both. However, prosecuting them for human error is unjust. Mistakes are bound to happen, however the frequency of them recurring should be reduced. In order to encourage pharmacists to learn from their mistakes, pharmacists should record and share their mistakes and learn from it so that it will not happen again. If recording their errors leads them to being criminalized, errors like these will go undetected and this will cause greater risk in their career4. Patient safety and dispensing guidance was published by the National Patient Safety Agency (NPSA) in 20076 and was sent to all pharmacies in the United Kingdom (UK)8. This measure was put in place to make sure that the dispensing process is foolproof and that any medication error would be minimized. More than 12,000 pharmacists signed a petition to change the law4 and decriminalize dispensing error. However abolishing the law against dispensing error removes the basic rights of public protection and this would also lead to a lower safety standard8. Therefore it the proposals were not designed to remove the threat completely, but to introduce new defenses3 to Section 63 and Section 64 of the Medicines Act 1968. In this way, pharmacists, who are guilty of offence committed under the sections mentioned above, would have to prove their innocence by meeting certain conditions3 stated in the new order. However, errors that cause death of the patient will still be subjected to legal prosecution3. The new ruling also requires pharmacists to inform their patients about the errors that may affect their well being so as to rectify the mistakes immediately3. This new order will not only encourage pharmacists to learn from their mistakes by recording the errors, but it also informs the profession about their responsibilities and consequences. As patients trust pharmacists to provide them the right medication8, it is only fair for pharmacists to be presented to the CPS for investigation when an error occurs. However, if pharmacists risk jail sentence due to dispensing error, prescribers who prescribe the wrong medication should too. Although this will create more stress for the profession, it will also build awareness to their actions. The Pharmacy Order 2015 will differentiate pharmacists, who are guilty of breaching the law, from their unintentional and deliberate mistakes. Therefore in conclusion, I agree that dispensing error should be criminalized only if pharmacists are unable to prove that the error was not done intentionally.
Many medication errors occur due to abbreviated words symbols, and dosage that cant be read and become misunderstood. These mistakes can cause harm if no one notices it. Many patients end up with a life threatening problem due to a medical error. A nurse might give the patient the wrong dose because of the handwritten abbreviation the doctor wrote is not clear. Many abbreviations are similar and this can cause complication. If abbreviations are similar the best thing to do is write the abbreviation completely out and always ask if not sure. Providing unabbreviated prescriptions, communication, and writing all abbreviations out can reduce errors in the healthcare setting. Another consideration would be to make sure in the healthcare setting written policies are mentioned and used.
Nurses were the professional group who most often reported medication errors and older patients were those most often affected in the medication errors reports analyzed for this study (Friend, 2011). Medication error type’s revealed omitted medicine or dose, wrong dose, strength or frequency and wrong documentation were the most common problems at Site A where the traditional pen and paper methods of prescription were used; and wrong documentation and omission were the most common problems associated with medication errors at Site B where the electronic MMS was introduced (Friend, 2011). Reports of problems such as wrong drug, wrong dose, strength or frequency, quantity, wrong route, wrong drug and omitted dose were less frequent at Site B (Friend, 2011). The reduced incidence of omission errors at Site B supports suggestions that an advantage of the MMS is easy identification of patient requirements at each drug round time slot. Despite the finding of less omission errors at site B where the MMS had been introduced, there was a relatively high frequency in the incident reports of medication errors related to both omission and wrong dose, strength and frequency at both sites (Friend, 2011).
Unver, V., Tastan, S., & Akbayrak, N. (2012). Medication errors: Perspectives of newly graduated and experienced nurses. International Journal Of Nursing Practice, 18(4), 317-324. doi:10.1111/j.1440-172X.2012.02052.x
Medication Errors one of the biggest issues happening in an acute care setting today . Although, Medications are given based on the five rights principles: the right patient, right medication, right route, right dose, and right time. Even with the five rights principles medication errors are still happening. However, some of the errors that are occurring are due to poor order transcriptions and documentation, drug interactions, proper drug name and not paying enough attention and environment factors.
...ort her actions, then Jack must do so as he is too responsible for making this situation known to the appropriate people. However, one must acknowledge how difficult this may be for Jack due to the long-standing relationship he has with Linda. It should also be apparent now that Linda’s actions are unjustifiable. She is not only acting unprofessionally and unethically by not delivering the medication but she is committing an illegal offence by falsifying records and stealing from the ward. To conclude, it is important to remember that the Department of Health and Children (2008) acknowledge that healthcare has originated in a world which is not flawless and that as humans, errors are possible. However, members of the healthcare system must try and prevent these errors from occurring where possible to ensure a high standard of care which is owed to the service users.
What classifies as a Medication errors? An error can occur any time during the medication administration process. A medication error can be explained as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer” (National Coordinating Council for Medication Error Reporting and Prevention, 2014, para 1). Rather it is at prescribing, transcribing, dispensing or at the time of administration all these areas are equally substantial in producing possible errors that could potentially harm the patient (Flynn, Liang...
While the intent of this legislation is to prevent fatal medical errors, threatening the loss of licensure for misreading prescription orders will do nothing to prevent the errors. In fact, it may even worsen the extent of the errors as it will likely lead to a decrease in the reporting of such errors due to fear of the consequences. This law also uses the word “gross negligence” to describe misreading an order, which is human error. Misreading an order is unintended
Everyone realizes that the people around them are not perfect and that sometimes people need to forgive and forget to move on with life. In some cases forgiving and getting are an option, but in others it may not. Depending on the circumstances what a person says now may be the last thing someone hears in their life because no one is promised tomorrow. Mistakes happen but people need to be careful with what they do. Life changes everyday and people wish they had one more chance to fix things that went wrong but sometimes you cannot go back in time.
Tzeng, H., Yin, C., & Schneider, T. E. (2013). Medication Error-Related Issues In Nursing Practice. MEDSURG Nursing, 22(1), 13-50.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
Medical errors can happen in the healthcare system such as hospitals, outpatient clinics, operating rooms, doctor’s offices, pharmacies, patients’ homes and anywhere in the healthcare system where patients are being treated. These errors consist of diagnostic, treatment, medicine, surgical, equipment calibration, and lab report error. Furthermore, communication problems between doctors and patients, miscommunication among healthcare staff and complex health care systems are playing important role in medical errors. We need to look for a solution which starts changes from physicians, nurses, pharmacists, patients, hospitals, and government agencies. In this paper I will discuss how does the problem of medical errors affect our healthcare delivery system? Also how can these medical errors be prevented and reduced?
Baccalaureate nurses are responsible for providing and ensure our patients safety. The knowledge from others mistakes can help informs nurses of extra precautions that we can take to ensure our patient’s safety. Risk Analysis and Implication for practice course helped me understand the steps I as a nurse can take as well as the facilities I work for to help reduce the number of medication errors that occur. Interviewing the pharmacist help me get a better insight to what facilities already have in place to help prevent medication errors. However like most things you have to have educated and compassionate caring staff to enforce and follow the guidelines set in place.
The findings of various studies suggest that to reduce prescribing errors hospitals should train junior doctors regarding the principles of drug dosing before they start prescribing, and enforce
Safety is the main concern in Health Care. Medication error is another aspect. It can be a preventable one. According to the National Coordinating Council for Medication error reporting and Prevention who states “A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer” (2018). The purpose of this paper is to show how different organizations identify, analyze different types of medication error, use evidence
Mistakes are actually a very influential part of a person’s upbringing in life. Mistakes shape a person’s character to make them who they are today. A mistake can teach someone many different life lessons that will better them as a person and make their lives more enjoyable. A person will commit a mistake usually when he or she is distracted. Distraction is the number one cause of mistakes in our world today. Many people are afraid of making mistakes, so they play it safe in life and don’t strive to achieve everything they are capable of achieving. This is a very bad thing. People should not be afraid of the potential mistakes there are to be made. Instead, they should focus more on the great lengths they could go in life by pursuing their goals. Mistakes will happen on life’s journeys,