So, you made an error?

Gary Choo, Numark’s head of information services, explains how to minimise the risks associated with dispensing errors

Pharmacists are humans and making dispensing errors is fairly common.There were nearly 13,500 reported incidents involving medication errors in community pharmacies in England and Wales in 2013-2014.1

This means that every one of the 12,500 community pharmacies in England and Wales had made a dispensing or medication error at some stage during the year. While the low rate of reporting is open to discussion, each error or incident has the potential to give rise to a complaint and ultimately a financial claim. In addition to this, there is also the prospect of an investigation by the GPhC, or PSNI (if you practise in Northern Ireland).

There has been a disproportionate rise in complaints over the past year. According to the GPhC2, the largest proportion of complaints come from members of the public (69 per cent). Complaints that have been referred to the GPhC go through several stages of investigation before ever getting to a Fitness to Practise Committee (FtPC). In 2014 only 7.5 per cent of complaints were heard by the FtPC.

The vast majority of complaints arise from dispensing errors. ‘One-off’ single dispensing incidents are usually dealt with through a letter of advice. Repeat errors are referred to the Investigation Committee. The GPhC has issued guidelines about dealing with dispensing errors.3

Action points

The guide lists a series of action points to be taken and a detailed description is included. A summary of the action points is listed below:

  • Establish if the patient has taken any of the incorrect medicine
  • Ask to inspect the incorrect medicine
  • Apologise
  • Never try to minimise the seriousness of a complaint
  • Make a correct supply of the correct medicine ordered on the prescription if appropriate
  • Establish the patient’s expectations
  • Provide details of how to complain to an ‘official body’ if requested
  • Try to establish what happened and what went wrong
  • Follow company procedures/SOPs for reporting errors and complaints
  • Record, review and learn from errors made
  • Notify the pharmacist who was on duty at the time
  • Inform your professional indemnity insurance provider

The key action in dealing with complaints is engaging with and apologising to the complainant. Making an apology does not in most cases constitute an admission of liability or guilt. It is also important that information about how to complain is readily available. If not, people will complain directly to the GPhC, NHS England, local councils and even local newspapers.

Sometimes, all people want is an apology and someone to take personal responsibility to ensure it does not happen again. This may prevent any further action. Unfortunately, there is a worrying trend in personal claims, reflecting an increasingly litigious society. Claims that involve solicitors can be extremely expensive. It is important that you are adequately protected and speak to your professional indemnity provider as soon as possible.

Preventing errors

Mistakes will always happen in a dispensary; the key is to minimise the chances of errors happening. One of the most important aspects in managing the risk of errors is staff engagement. It is important to instil a risk minimisation approach where every member of the team has to play a part in preventing errors.

Errors are usually a result of a chain of events and not usually caused by a single action. Let’s take a carton of 28 amlodipine 10mg tablets, for instance (see panel). From receipt to storage and dispensing, anyone from the shop assistant who greets the driver, the dispenser who puts the carton away and the patient that receives it, has some risk attached to the process. A ‘simple’ dispensing process can be associated with numerous risks.

By understanding the risks associated with each step of the dispensing process, pharmacists can identify who is associated with each step. Training and awareness of the roles of each member of the dispensary team is the first and most important step in minimising errors. Use this risk assessment process to analyse where potential errors may occur and take steps to minimise the probability of it occurring.

Errors can and will happen in dispensing. It is how you identify and minimise the risk as well as training your team that will help you through the difficulties of going through a dispensing error process.


  1. NRLS Quarterly Data Workbook up to Dec 2014 ; Table 10: Reported incident types in community pharmacies by quarter, Oct 2013 – Sep 2014.
  2. Personal communication with the General Pharmaceutical Council, October 2015
  3. General Pharmaceutical Council. Responding to complaints and concerns. Guidance Note: September 2010.




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