The PSI's Professional Conduct Committee (PCC) recently heard a case in which a minor was supplied with twice the prescribed dose of their medicine Enbrel® (etanercept) solution for injection, over the course of approximately one year.
The pharmacist had dispensed the medicine in error from the original prescription and this error was then repeated in the subsequent supplies as the patient medication record (PMR) was referred to rather than checking or endorsing the original prescription.
When a second prescription was received, the wrong dose was still supplied to the patient for a further 6 months. The error was only discovered when a third prescription was presented at the pharmacy in respect of the same patient.
The pharmacist then informed the patient’s parent of the error, but failed to inform the superintendent for the pharmacy of the dispensing error, or the patient’s GP or treating consultant that the patient had received an overdose of their medicine for 11 months.
The superintendent pharmacist learned of the dispensing error through subsequent queries raised by the patient’s parents approximately 2 months after the error was discovered, however, the superintendent pharmacist also did not inform the patient’s GP or treating consultant of the overdose the patient had received.
This case brings to light how important it is that the original Rx is referred to at each and every dispensing. Once an error is discovered a strict protocol must be followed as specified in the pharmacy's relevant SOP to ensure harm minimisation (such as contacting the patient's GP or other prescriber as appropriate) and error recording and reporting to ensure lessons are learned and same mistakes do not repeat again.