Team dispensing: who is responsible?

When a pharmacist dispenses carbimazole instead of carbamazepine, where does responsibility lie?

In its latest communication to members, Pharmaceutical Defence Ltd looks at a common case scenario to illustrate how to identify the pharmacist responsible for a script.

PDL notes that when a script is dispensed, the Pharmacy Board expects that the pharmacist responsible for it can be identified.

“It is common practice in many dispensaries to have multiple pharmacists involved in the dispensing of a single item,” says PDL.

“One pharmacist or technician may input the information, another may assemble the prescription, while a third could do the final check and clear the script for collection.

“In this scenario, the initials of the pharmacist entered into the computer originally will not necessarily reflect who does the final check and is therefore responsible for the dispensing.”

The case scenario involves a busy pharmacy which made a dispensing error whereby carbimazole was provided on a script that called for carbamazepine.

This error is unfortunately relatively common, says PDL.

“In this particular case, the consumer suffered physically and filed a complaint with AHPRA who investigated.

“The pharmacist named in the complaint stated that he believed he was not responsible for releasing the script and in fact it could not accurately be determined who had given the final clearance.

“As a result of this failure to identify the dispenser, AHPRA investigated the pharmacy owners in addition to the employee pharmacists, as they had ultimate responsibility to oversee all practices and protocols in their pharmacy.”

Traditionally, the initials in the computer were deemed to be the person responsible for the dispensing.

However, with the advent of ‘team dispensing’, the initials alone cannot be relied upon, PDL warns.

“A possible solution to this problem is to have the pharmacist doing the final check initial the dispensing label on the product to identify themselves. Though this alone is not error proof as the packing with the attached label can be removed or discarded when the product is finished.

“Another way to identify the responsible pharmacist is to initial the computer sticker placed on the actual prescription, or duplicate, which can be retained by the pharmacy and accessed at a later date if required.

“No one process of identification is stipulated but all pharmacies must have clear protocols in place to satisfy the need to identify the dispenser.”

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  1. Rohan Elliott

    Technology is the solution, not initialing the label or paper script. At the hospital where I work, the dispensing system records who typed the script (could be a pharmacist or tech), who scanned the item when it was dispensed (again this could be a pharmacist or tech), and who did the final check (pharmacist). The latter two records are automated via the use of bar code scanning. So you can easily see who did what. This should be mandatory in all dispensing systems.

    • Karalyn Huxhagen

      This does need to become mandatory at the three levels. Have sat on many AHPRA cases where pcists plea that thry did not dispense these items but a tech did and an unknown did the checking. We currently have an issue with MHR where the disp tech dispenses under their initials and those items Do not go in the MHR as the only data collected relates to the pharmacists who are logged on the pharmacy IHO.

  2. Cogrady

    I think all 3 people should share the burden

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