Judith Marshall

1. 1. drug errors in pharmacy records

   “The Pharmacy's Errors Book shows a number of drug errors (including higher or lower dose tablets and the wrong drugs) over a number of years. It is not clear whether and to what extent such internal records are policed.”

2. 2. fatal dispensing error of controlled opiate

   “Despite a system of checking by a colleague it is apparent that there can be a mistake in dispensing medication which in this case was a controlled opiate drug. The consequences were fatal.”

3. 3. lack of software to detect prescription errors

   “It is not clear whether there is any software, obtainable from the Department of Health or elsewhere, that could read prescriptions and raise an alert if the label sought to be created or if the drug sought to be dispensed is wrong in identity or amount. This would be of particular significance when a high risk drug is dispensed or when a drug is dispensed in an unusual quantity, dosage or form.”

4. 4. human error in dosage interpretation

   “Mandatory procedures requiring a 'read-back' of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors. In so far as the error in this case can be attributable to 'Human Error' it is concluded that the dispensing pharmacist focused on the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules.”

5. 5. lack of end-of-day verification of dispensed drugs

   “A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.”

6. 6. absence of central prescription error database

   “There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”

Linked reports