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A power imbalance between surgeries and pharmacies meant I was forced to take responsibility for something I had no responsibility for. And that was simply wrong, says Terry Maguire…

In March, I had just completed my submission for the Quality Assurance Framework payment and in the round, I was satisfied that we operate effectively within our SOPs, audits and training and this ensures a safe and efficient working environment. 

Then we had an incident. Our driver, who each morning collects prescriptions from all the local surgeries – to reduce costs, we share with other pharmacies – had just been replaced.

I first became aware of a problem when a patient arrived requesting a prescription which just happened to be for a controlled drug (CD).

We had no record of receiving the script, so we referred her to her GP but when she contacted the surgery, she was told it was in the pharmacy.  Somewhat frustrated, she returned to us stating the problem was ours.

The fact this was for a controlled drug did focus my attention

Of course, as most pharmacies will know, this is not a rare event and usually the prescription is located, mislaid somewhere or most commonly, hasn’t left the surgery or has arrived mistakenly in a different pharmacy.

The fact this was for a CD and we had a new driver, an employee of another pharmacy, did focus my attention. Following an internal search, we contacted the other pharmacies who confirmed they didn’t have the script and the new driver confirmed she was unaware she had received it; she had merely been given a bunch of prescriptions in an envelope by the receptionist.

When contacted, the surgery was adamant that this specific prescription had been handed to the driver and she had signed for it; they were happy to share the signature.

The only solution, we were informed, was to ring the police and on receipt of a crime incident report number, the surgery would consider issuing a duplicate.

I contacted the driver again to confirm exactly what had happened. She told me she had been asked to sign one sheet of blank paper but was not given specific scripts, merely handed the envelope and that was passed on to us.

Incident absorbed a large part of my morning 

This incident had absorbed a large part of my morning when I needed to get on with all the other prescriptions and other matters. Two phone calls to the surgery took over 45 minutes, then I waited 15 minutes to get through to the police service to report ‘an incident’ that I doubted had actually occurred.

I finally got the crime incident number and was surprised the call handler commented that it was not unusual to have a missing prescription incident reported from a member of the public but she hadn’t had this from a pharmacy before.

With the crime number reported, I thought the matter was resolved. Then I had a call from a colleague at the Strategic Planning and Performance Group, our health board.

She had been informed by a medical colleague that this CD incident had been reported by the surgery and as we were named in the incident report, she was asked to ensure we had followed procedures.

It was a mammoth task to retain my professionalism, particularly when my colleague seemed unconvinced of my explanation. She asked that I report the incident on a reporting app recently set up by the Department of Health and she would send me the link.

A day later, we got a phone call from the surgery and to their credit, they owned up that it was their fault, apologising for the hassle.  A driver from another pharmacy had just returned the prescription and, as they had already issued a duplicate, they would destroy it. This, sadly, was not a one-off.

No SOP will stop this incident occurring because it is mostly beyond my control

So, have I learned anything from this incident? A lot, actually. The electronic transfer of prescriptions will stop this hugely inefficient system of paper-based prescriptions. But that’s in dreamland at least until 2032.

Back in the real world, the driver signed for 19 prescriptions, not for 20, so a new SOP is now in place, a records book signed for CDs. But no internal SOP in my Quality Assurance Framework will stop this incident occurring again because it is mostly beyond my control.

I’m impressed with the absolute certainty GP reception staff have in their prescription management SOPs. These are, it seems, faultless and where followed they cannot be wrong.

One of the reasons for this is the power imbalance between surgeries and pharmacies. I should not have been forced to take responsibility for something I had no responsibility for.

And I should have been more assured by my own quality systems.

Terry Maguire is a leading pharmacist in Northern Ireland.