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Kenacomb ear drops dispensed instead of prescribed chloramphenicol eye drops (04HDC08685)
Download Kenacomb ear drops dispensed instead of prescribed chloramphenicol eye drops (04HDC08685) (PDF 142Kb)
(04HDC08685, 21 June 2005)
Pharmacist ~ Pharmacy ~ Dispensing error ~ Storage systems ~
Stock management ~ Professional standards ~ Vicarious liability ~
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
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