A dispensing error through the eyes of the pharmacist

To make errors is a human trait, writes Johnathan Laird

A pharmacist I used to work with once told me that you should worry about all dispensing errors. However, it is the errors that you never become aware of that should worry you most.

Johnathan Laird
Johnathan Laird

For a pharmacist, this is a chilling thought.

I have made dispensing errors.

To a lay person the sentence above may appear innocuous. However, as the law stands at the moment [in Scotland] an admission of this nature could lead to criminal proceedings. For the majority of pharmacists it never comes to this, because the harm caused is either non-existent, not clinically significant, or cannot be attributed to the error.


It is the minority of pharmacists who suffer the criminal consequences of making a dispensing error. I highly recommend you read this story about a dispensing error which, very unfortunately, led to the death of a patient three days later. The judgement in that case was made and this blog is not about questioning it in any way. I would like to explore how that moment and the days and weeks after may have felt for any pharmacist in a similar situation.

Making an error

The first clue is often the patient walking up the shop towards the dispensary with an already, crumpled, previously opened dispensing bag.

Your pulse quickens.

Could this be your career-ending moment?

Wrong medicine

The patient asks to speak to the pharmacist. You oblige promptly, heading over with a quiet sense of impending doom. The box is presented and you take a look. It appears at first glance that there is nothing wrong, because it looks like a felodipine box.

But, it turns out that the felodipine is actually a box of co-tenidone, which looks very similar. Your mind goes into overdrive as you will the whole situation to just disappear. It does not. The root cause analysis begins immediately. Human nature is such that you seek to blame. It is at this point that I fall back on my instinct for professionalism.

First things first

My only concern at this stage is the patient. Luckily they tell you that in this case none of the incorrect medicine has been taken. You have already made the error, so making things right for the patient is really important.

In my view you should always apologise.

It is then about reporting the error, completing a thorough root cause analysis and sharing findings with your team. These are all processes that must be completed to meet our professional obligations. How you feel after making an error is another matter. I’m quite sure that every pharmacist copes in individual ways, but cope they must.

The feeling after I make a dispensing error is horrible. I feel professionally exposed in these situations. It feels like I have failed the patient that I work so hard to proactively protect. It can feel like a rug being whipped from beneath me.

Next time

The relative certainty about dispensing errors is that no excess of optimism or denial will wash away the cold hard fact that there will be a next time, or that the next time the error could have serious consequences. I fend off this anxiety by redoubling my efforts into making things as safe as I possibly can in the dispensary.

Johnathan Laird MPharmS is a community pharmacist working in rural Aberdeenshire, Scotland. He contributes to Pharmacy in Practice and The Pharmaceutical Journal.

This post originally appeared on Pharmacy in Practice.

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  1. Paige

    Everyone will make a dispensing error in their career, guaranteed. Some might even be serious, that’s okay. Remember you’re a human you’re entitled to make mistakes, its part of the non-perfect nature of humankind. Whats not okay is to do so without a raft of error mitigation policies, do everything in your power to stop them or limit them. You know what I’m talking about.

    The next step is how to handle them. Don’t under any circumstances let a shop assistant do this part, come out from your hidey hole and explain what you’ve done, what consequences it could have to the patient if any, sincerely apologise directly to the patient. Explain how it happened, and how you are going to make sure it never happens again. Give them their correct medicine at no charge, even if it was more expensive than the incorrect one you dispensed. Then pray to god they aren’t in a bad mood.

  2. Notachemist

    The impact of a dispensing error on a pharmacist (or any medical error) is known as second victim syndrome. Most pharmacists are very upset and may even experience trauma to know that an error has occurred. As well as the good advice form Paige it is also so important to notify your indemnity insurer to ensure that the situation is documented while it is fresh in your mind. Sometimes an outcome from a dispensing error may occur many months and even years later (especially if it is a coronial investigation). At that time your contemporaneous notes will be vital to you being able to provide evidence about what happened. Also your indemnity insurer may not be able to cover you if the error has not been reported. Good indemnity insurers will also offer you support at the time. If you need to talk about an error to an independent third party you can also call the Pharmacists’ Support Service for a listening ear and support over the phone on 1300244910 every day of the year between 8am and 11pm EST. You can speak anonymously and confidentially to a trained volunteer who is a pharmacist or a retired pharmacist.

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