On 6th February 2014, Mrs Ethna Walsh, a 67-year-old grandmother, was prescribed Prednisolone Tablets 5mg by her doctor. Having taken the first dose of 8 tablets she became ill, collapsed, was rushed to hospital and was dead within two hours. She had been dispensed propranolol 40mg tablets by mistake.
Martin White, her pharmacist, fully cooperated with the investigation and admitted that he had been responsible for all steps involved in dispensing the medicine. He is an experienced pharmacist and has worked in a busy dispensary for many years with no apparent previous dispensing errors. He could not explain during Police interviews how the error occurred.
Dispensing errors in pharmacy practice occur at a relatively low frequency. According to a National Patient Safety Agency (NPSA) report of 22,000 medicines dispensed there were 26 dispensing errors a frequency of approximately 0.1%. Dispensing errors that cause harm to patients are at a lower rate still at about 0.02%.
The NHS National Patient Safety Agency has issued a Freedom of Information Letter in 2009. This states that in the period Jan 2005 and June 2009 there were 7 incidents reported relating to transposing of prednisolone for propranolol and vis-versa. The outcomes from these transpositions were; 1 death, 1 moderate harm and 5 no harm. Two of these reports were from community pharmacy and 5 were from hospital. The death and moderate harm reports were from prednisolone being transposed for propranolol.
Similar named drugs juxtaposition on pharmacy shelves are a main source of dispensing risk and error and pharmacy insurers identify the risk potential for transposition during the dispensing process regularly in correspondence with pharmacists. Over 80% of dispensing errors are picking errors i.e. selecting the wrong medicine.
It was hard to pinpoint why this tragic error occurred and the judge agreed it was a “momentary lapses of concentration”.
Martin White is a good man, a loyal, hardworking employee and, by most standards, he was a good pharmacist – he has now decided to leave the profession. I’m sure he never thought it would come to this. Over his 24 years career, most of it working in the same business, he never envisaged that, one day, he would make an error and kill a patient. The shock, the horror, the personal turmoil, and the very public punishment; the criminal proceedings and the stiff sentence (4 months suspended). He likely will be asked to appear before the pharmacy regulator. All community pharmacists, apart from the rightously deluded, have made similar mistakes but gratefully with far less tragic consequences.
But Martin White is not the victim in this all of this, you might think. A family lost a much loved grandmother in the most tragic of circumstances and someone must take responsibility; the public must be protected. No one disagrees but what is the price that must be paid by a professional person for a momentary lapse of concentration? Mistakes, in any human endeavours, happen. We need systems to reduce that risk and when mistakes happen we need to identify the causes and those responsible and take steps to ensure similar mistakes do not happen in the future. I don’t know which aspect of the criminal proceedings that have just concluded will give that public assurance.
The legal system is unfairly punitive towards community pharmacists. Had a GP, dentist, social worker or community nurse made a mistake with similar consequences they would not have been held criminally liable unless it could be proved they were guilty of manslaughter through gross professional misconduct. For a pharmacist a dispensing error is an absolute offence; by making a mistake pharmacists become criminals. For many years work has been on going to address this anomaly but we still await the necessary changes.
Terry Maguire is a Belfast Pharmacist.