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Kenacomb ear drops dispensed instead of prescribed chloramphenicol eye drops (04HDC08685)

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(04HDC08685, 21 June 2005)

Pharmacist ~ Pharmacy ~ Dispensing error ~ Storage systems ~ Stock management ~ Professional standards ~ Vicarious liability ~ Right 4(2)

A 58-year-old man's general practitioner prescribed chloramphenicol eye drops to treat conjunctivitis. The man complained that a locum pharmacist did not provide services of an appropriate standard when he mistakenly dispensed ear drops.

The ear drops had been incorrectly stored on the bottom shelf of the pharmacy refrigerator where the eye drops were usually stored. The error was not picked up when the pharmacy technician queried whether drops or ointment were to be dispensed, as the pharmacist answered the query without re-checking the prescription.

The man discovered the error when his eyelids swelled and his eyes became increasingly irritated after using the drops three times. The GP referred the man to an ophthalmologist, who confirmed that, while the ear drops may have aggravated the infected eyes, they were unlikely to cause permanent damage.

When the man reported the mistake, the locum pharmacist admitted the error and apologised. He contacted the man's GP and the pharmacy owner to inform them of the error and to apologise. Although he identified the cause of the mix-up as the incorrect shelving of the ear drops, when he did a stocktake there was not a consequent discrepancy in the stock levels of the eye and ear drops. That the error was not reflected in the stock levels was disturbing. A pharmacy's stock check should be consistent with the stock records at any time.

It was held that the locum pharmacist breached Right 4(2) by failing to check the labelling against the prescription, as required by professional standards. The pharmacy was found vicariously liable. While the pharmacy had an adequate dispensing policy, the lack of shelf labelling and the incorrect placement of stock in the refrigerator had contributed to the error. The pharmacy responded by labelling the shelves and undertaking a weekly stocktake.