How should we deal with pharmacists who make mistakes?


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.


  • Korhomme

    I gather that the underlying reason, as is so often the case today, is the pressure of overwork. It is the recognition of this which is vital, followed by real action to ensure, as far as possible, that such errors don’t happen again; more staff.

  • Muiris

    As a GP, I feel for the pharmacist, as a person, for the bereaved family. I don’t believe that if I made a similar mistake ( and I am not righteously deluded, but haven’t been caught), that the consequences, rightly or wrongly, would be any less.

    If medicines were stored by drug class, rather than alphabetically, errors would be within a class, usually, and less likely to be detrimental, as well as the safety net of dissimilar names making errors less likely.

  • doopa

    Is this not a prime example of field ripe for replacement by the machines, who don’t suffer from fatigue?

  • Superfluous

    I’d like to think I’m pretty experienced at my job – 15 years in fact. And I make mistakes all the time, especially when I’m under pressure. I can’t imagine how difficult it is to maintain standards when mistakes like this can cause genuine (rather than purely financial) harm.

  • Borachon

    Yeah that’s right, because all pharmacists do is put tablets in a bag, right?

  • doopa

    Perhaps we can start with the putting tablets in a bag part and then see how we get on.

  • Brian O’Neill

    My local pharmacist has a new dispensing machine. They scan your script and a robot arm picks the drugs and dispenses them down a tube.

    I asked the pharmacist why he is there at all, why can’t they just make it a big vending machine? His reply was ‘Good point’.

    Pharmacists are actually very well trained. They should be advising on ailments, reviewing patients drugs for contradictions etc. But instead they have let themselves be deskilled so most of the job involves picking boxes of shelves. And for this we pay them 50K per year.

    They really need to make themselves more relevant or they will be first of the health professionals to be replaced by robots.

  • Sundrive Road Jordans

    To me this is part of a trend that “somebody” must be to blame for every bad thing that happens. While I don’t think that we can accept the attitude that accidents just happen I think that we have to move past looking to blame an individual for a system failure.
    The same pharmacy regulator that will now take the unfortunate pharmacist to task is also the one that is happy to allow a pharmacist to dispense hundreds of items per day unassisted or that doesn’t set any limits on the numbers of technicians per pharmacist. Down south we have a regulator who is content to have pharmacists who cannot speak English properly or who do not even know the laws and regulations. Their attitude is one of the politics of the latest atrocity.
    The race to the bottom is a recipe for disaster in relation to errors. Lowering the price paid ultimately leads to a lowering of standards. I don’t know of any case of the opposite, especially in healthcare.
    This is a tragedy for both the patient and their family and the pharmacist. The authorities and the regulator are happy to throw him under a bus to create a distraction from their own failures.