A Complaint Involving the Dispensing of a High Tech Medicine

The Professional Conduct Committee (PCC) heard a complaint in which a patient had been supplied with an incorrect quantity of a High Tech medicine, Xeloda® (Capecitabine) tablets, on two separate occasions and that the medicine supplied was labelled with an incorrect dose on two separate occasions.

  • A fax of a High Tech prescription was sent from a hospital to a community pharmacy and read: Xeloda® tablets ‘1800mg Po bid x 14/7 on, then 1 week off’. Written instructions on the prescription also stated: ‘Repeat every 21 day cycle x 8 cycles’, ‘Dispense one cycle at a time’ and ‘Dispense exact number of doses’.
  • To make up the prescribed dosage of the first cycle of treatment (1800mg twice daily for 14 days) the patient required:
  • Xeloda® 500mg x 84 tablets; Take three tablets twice daily for 2 weeks, then 1 week off
  • Xeloda® 150mg x 56 tablets; Take two tablets twice daily for 2 weeks, then 1 week off
  • On the date of the first review when the High Tech prescription was to be dispensed, the Xeloda® 150mg tablets were not in stock in the pharmacy, the patient was not waiting on the medication and the Pharmacist working in the pharmacy that day gave evidence at the Inquiry that he wanted to contact the prescribing Consultant to clarify the dose.
  • The Pharmacist gave evidence that he set the prescription aside and placed a “post-it” on it indicating that the prescription would be dealt with the following week.
  • A staff member working alongside the Pharmacist gave evidence at the Inquiry that on the date of the first review she generated a label for Xeloda® 500mg tablets from a previous supply recorded on the Patient Medication Record (PMR) in order to compare it to the new prescription as the dosage had changed. The previous dosage was Xeloda® 500mg tablets with instructions to ‘Take three tablets twice daily Monday-Friday only for 6 weeks in total’. This label was set aside with the faxed prescription.
  • The following working day, the Pharmacist concerned was not on duty, the post-it was not seen and Xeloda® 500mg tablets were dispensed using the label re-printed from the PMR.
  • Later that week a pharmacist at the hospital where the patient was receiving treatment contacted the pharmacy and informed the Pharmacist that the patient had been supplied with 90 x Xeloda® 500mg tablets labelled with an incorrect dose. The hospital pharmacist also informed the Pharmacist concerned that the Xeloda® 150mg tablets had not been supplied to the patient.
  • New labels for Xeloda® 500mg tablets and Xeloda® 150mg tablets were printed, and Xeloda® 150mg tablets were prepared and collected by the patient.
  • The next day the hospital pharmacist rang the pharmacy again and informed the Pharmaceutical Assistant on duty that the patient had collected 60 x Xeloda® 150mg tablets from the pharmacy when they should only have been supplied with 56 x Xeloda® 150mg tablets and that the label read ‘Take one tablet twice daily’ when the dose required for the Xeloda® 150mg was ‘Take two tablets twice daily’. The patient had contacted the hospital pharmacist as they were confused as to how many to take.

At the Inquiry before the PCC, the Pharmacist who was the subject of the complaint undertook not to repeat the conduct to which the complaint related and consented to being censured by the Council of the PSI. Following the submission by the PCC of its report to the Council of the PSI, the Council censured the Pharmacist.

Important Learnings

The sequence of events that caused the errors in this complaint involved a number of people over a number of days. Learnings from this complaint should be shared with all staff members and you should review your own practice to help ensure a similar incident doesn’t happen in your pharmacy.

The PSI has produced a practice notice on good dispensing practice for High Tech medicines.

This complaint highlights the following important learning points:

  • There should be an agreed procedure for ordering, storing and dispensing High Tech medicines, written down in the form of a Standard Operating Procedure (SOP). Following clear SOPs ensures consistent performance of a task to the required level and ensures that the system is as robust as possible. All new staff members should be trained to use and follow the SOPs, and they should be regularly reviewed to ensure that they are fit for purpose. SOPs should be unique to your pharmacy and tailored to your dispensary design and staff.
  • There should be a clear procedure for recording and communicating important information regarding patients’ prescriptions, for example, queries to be followed up with the prescriber, and the ordering of medicines. This should be in a format and place that is practical, cannot be misplaced or lost and can be used by the whole pharmacy team. This communication procedure should ensure that patient care is consistently maintained regardless of which pharmacist or staff member is on duty.
  • When dispensing a medicine which is owed from a previous day it must be checked against the original prescription. Dispensing a medicine from a dispensing label, PMR or an owing note, often compounds an error made on the first dispensing.
  • The patient must always be counselled on the correct use of their medicine, potential adverse effects, and precautions for use, and how to store the medicine. Patient understanding should be confirmed. This can also serve as a final check and help to pick up on an error that may otherwise have been missed.
  • Counselling with regards to a High Tech medicine is particularly important as these patients are often very sick and the medicines can be particularly harmful if used incorrectly. Even if only one patient in the pharmacy is on a particular High Tech medicine it is imperative that the pharmacist knows what it is being used for, so that they can counsel the patient appropriately.
  • It should be noted that patients prescribed chemotherapy can tend to be over-compliant, as opposed to under-compliant, with regards to taking their medications, and therefore it is important that the exact amount needed by the patient for their treatment regimen is supplied.
  • If two members of staff are involved in the dispensing process there is a risk that both may rely on the other to be rigorous and hence neither give the task their full attention. There should be clear lines of accountability between staff members, the pharmacist being ultimately responsible for all medicines supplied from the pharmacy.
  •  An error log must be completed for all errors made in the pharmacy, and the staff members involved informed of the error. Recording errors should not be used as a way to blame individuals, but rather to encourage an environment of openness and learning, so that procedures can be reviewed and amended, and practices changed to guard against a similar error occurring again.