Understanding dispensing error legislation

With dispensing error legislation finally written into law, Tess Fenn looks at what this means for pharmacy technicians

The 16 April 2018 saw the commencement of The Pharmacy (Preparation and Dispensing Errors – Registered Pharmacies) Order 2018. This marks a major step forward for pharmacy professionals as the change in the law provides a new defence against two of the offences outlined in the Medicines Act 1968: preparation and dispensing errors.

Preparation and dispensing errors

As designated in sections 64 and 63 of the Medicines Act 1968, preparation or dispensing errors can include:

  • An ingredient that is omitted or added when making up a medicine
  • A medicine intended for another patient being dispensed to the wrong patient
  • The wrong medicine being dispensed
  • The medicine being dispensed at the wrong strength or in the wrong dose.

This list is not exhaustive, but I am sure you will have seen some of these errors at one time or another, probably as ‘near misses’ that are rectifi ed before the medicines are issued to the patient. I know in my experience that issuing medicines to the wrong patient can occur if the wrong patient steps up to collect a prescription called out for another.

The new legislation

The preparation and dispensing error offences still exist but, providing that certain conditions are met, the new legislation offers a complete defence. From now on, if an inadvertent (unintentional) error goes out to a patient, the defence applies to criminal offences (harmful acts that are punishable by law), if the pharmacy professional was acting in the course of their professional duty and also if:

  • The prescription was dispensed from a General Pharmaceutical Council or Pharmaceutical Society of Northern Ireland registered pharmacy
  • The supply or sale was made from a prescription (so prescribed medicines only) or a ‘direction’ (in hospitals where a supply can be made at the request of the prescriber, i.e. on a patient’s medication chart)
  • They or another responsible person has taken prompt steps to notify any affected patients when the error came to light, unless they are reasonably satisfied that this was not necessary, for example if the patient already knew, such as them raising the error to the pharmacy.

Acting outside the course of the profession

It’s worth noting at this point, what is considered as not ‘acting in the course of their professional duty’. This could be deliberately failing to have due regard for patient safety or using professional skills and knowledge for an improper purpose.

As indicated during the public consultation, not following a standard operating procedure (SOP) is not considered as acting outside of the ‘course of their profession’ as, on occasions, this might be in the best interest of the patient and professional judgement should be used. An example of this might be that a pharmacy premises has a SOP that says that all supplies must be dispensed in accordance with prescriptions presented. However, issuing a lower strength medicine to a patient and doubling the quantity of the medicine, if there is a stock shortage, would be in the best interest of the patient.

At present, this change in legislation only protects those working in registered pharmacy premises and so this does not cover all pharmacy technicians. There are plans, however, to consult shortly on further legislation which will widen the defence to other pharmacy service areas, such as unregistered hospital pharmacies, prisons and care homes. It is expected that the same or similar defences will apply, but watch this space so that you can have a view on this.

Another major aspect of this new legislation is to help us, as the pharmacy professions, learn from errors made through greater reporting and sharing. My column next month will focus on how, as pharmacy technicians, we can make this happen and input into better patient safety.


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