Editorial

From the desk of the editor

Welcome to the first homepage edition of i2P for 2012.
In many ways it has been a slow start to the New Year because of having to deal with the “leftovers” from 2011.
One of those items for i2P was that a third-party provider to the site did not advise of a code change to the security section in our subscribe panel, creating a range of frustrated subscribers not able to get on board.
We apologise to all those potential subscribers who were unable to register with us in the second half of 2011, but if you try once more you should have no problem.

read more
open full screen

Columns

Recent Comments

Click here to read...

Past Editions

Volume 1 Number 1
Volume 1 Number 2
Volume 1 Number 3
Volume 1 Number 4
Volume 1 Number 5
Volume 1 Number 6
Volume 1 Number 7
Volume 2 Number 1
Volume 2 Number 2
Volume 2 Number 3
Volume 2 Number 4
Volume 2 Number 5
Volume 2 Number 6
Volume 2 Number 7
Volume 2 Number 8
Volume 2 Number 9
Volume 2 Number 10
Volume 2 Number 11
Volume 3 Number 1
Volume 3 Number 2
Volume 3 Number 3
Volume 3 Number 4
Volume 3 Number 5
Volume 3 Number 6
Volume 3 Number 7
Volume 3 Number 8
Volume 3 Number 9
Volume 3 Number 10
Volume 3 Number 11
Volume 2012 Number 1

i2P Archives

Health Politics

EPublications

Click here for a list of epublications

Dispensing errors and criminality

• Printer-friendly version
• Send to friend
• PDF version
• Share

Neil Johnston articles by this author...

Neil Johnston is a pharmacist who trained as a management consultant. He was the first consultant to service the pharmacy profession and commenced practice as a full time consultant in 1972, specialising in community pharmacy management, pharmacy systems, preventive medicine and the marketing of professional services. He has owned, or part-owned a total of six pharmacies during his career, and for a decade spent time both as a clinical pharmacist and Chief Pharmacist in the public hospital system. He has been editor of i2P since 2000.

Two-year old Emily Jerry of Ohio died on March 1, 2006 as a consequence of an error made by a pharmacy technician and pharmacist.

open this article full screen

The consequences for the pharmacist continued.
He was charged with criminal actions and he pleaded guilty to a charge of involuntary manslaughter.
In August, 2009, he was sentenced to six months in prison, six months of home confinement with electronic monitoring, 400 hours of community service, a $5,000 fine, and payment of court costs.
His prison term concludes shortly.

A similar situation occurred with a UK pharmacist, Elizabeth Lee, who also made an error under pressure-cooker workplace conditions
Both the above pharmacists have now criminal records and do not work as pharmacists.

One has to ask why the necessity for criminal prosecutions for an unintended error?

Pharmaceutical associations ignored the US pharmacist and no attempt has been made in the US to decriminalise dispensing errors to this point.
An entirely different response occurred in the UK where pharmacy organisations rallied around Elizabeth Lee sympathetically and immediately lobbying began to decriminalise dispensing errors.

But could the same thing happen here in Australia?

I decided to find out.

I made a telephone call to the PDL office and described the circumstances regarding the US incident and asked if whether a similar response would occur here in Australia i.e. a dispensing error that resulted in death or damage to a patient – would it attract criminal charges?
I also explained that the question was a hypothetical.

The PDL office person could not answer the query, but I was referred to the solicitors that acted for PDL.

I asked the same question of the young solicitor I was eventually transferred to.

The answer in regard to criminality is, “Yes, maybe.”

I was walked through the following process.

If a death eventuated, the coroner would be the first official person to be involved.

After a thorough investigation a finding would be made.

That finding may then be referred on to a Pharmacy Board hearing to determine any professional penalties such as deregistration, or the coroner may direct that the Director of Public Prosecutions take action if there was evidence of “reckless disregard” in the prescription checking process.

At that point the nature of the action takes on the mantle of a criminal prosecution and yes, a gaol sentence could result.

I am adamantly opposed to the concept of criminal prosecution for a genuine dispensing error, and I would also not like to think that any close family member may be killed or damaged by a pharmacist not doing their job properly.
No professional pharmacist would seek to avoid responsibility for any of the daily activities they may be involved in.
However, the more remote the dispensing circumstances are, the easier it is to have an error occur on your watch.

For example, with robotic machinery moving in on the dispensing process and the preliminary checking processes delegated to a technician, there are less dispensing “hooks” to allow a certain level of cognition to occur.

Errors may slip through more easily.

In these days of financial problems on a global scale, liquidity in small businesses as well as public hospitals can result in staff cutbacks and additional pressures on the pharmacist in charge of a dispensary.
If this is already occurring, you may need to flag and document any potential for errors occurring.

If you are not listened to, you may have to consider resigning and find a better workplace – one with less stresses.

Errors do not always occur is fast-paced working environments.
You can be working in a pharmacy environment that by any measure is slow, by virtue of total number of scripts dispensed in any given hour or over the day.
It only takes a few minutes for a pressure situation to develop – the dispensary technician goes to the toilet while simultaneously the pharmacy assistant walks out to get the morning tea.
You suddenly notice that you are alone as new patients walk in and you break off to accept their scripts.

Now you have a script backlog and the telephone rings.

You begin to feel desperate and focus begins to fade with the error potential rising by the second – and the staff have only been absent for two minutes by this stage.
It requires great discipline to break the cycle that is starting to happen.

With absentee owners, sausage machine dispensaries, power hungry dispensary technicians, poor managers and management processes – let these all ring alarm bells lest you suffer the consequences of an error unsympathetically supported by your employer.

In the case of the pharmacist involved above, he was dismissed from his employment (along with the technician) as well as being subsequently deregistered.

I wonder if he has retained some sense of sanity?

I cannot see one shred of public benefit from all the punitive measures heaped upon this pharmacist.

Clinical Newsfeed

Click here to read more...

Research Reports

Practice Development

Information Technology

Indigenous Health

Preventive Medicine

i2P Alliance Partners