Common dispensing errors resulting in indemnity claims (UK)

09 Jul 2019

Common dispensing errors resulting in indemnity claims (UK) - Superintendent update

Dear Superintendent,

I would like to highlight some commons types of dispensing errors in my update today which have resulted in significant indemnity claims against pharmacies. A number of the claims have involved monitored dosage systems (MDS).

Example 1: dispensing patient returns

A significant claim has arisen from an error involving patient-returned vials of heparin which were accidently re-dispensed to a pregnant patient. The patient had administered a few doses of heparin before realising that the vials had been used before, and alerted the pharmacy. The pharmacy accepted that the heparin vials were patient-returned medicines which had been accidently re-dispensed. Once the patient realised the error, she was treated with preventive medication against the potential risk of infections such as HIV and hepatitis B. The patient went on to give birth to a healthy baby. However, the experience allegedly resulted in a significant ongoing psychological impact on the patient, both during her remaining pregnancy and after.

A key element which resulted in this error was the failure to segregate and store patient-returned medicines appropriately, and a potential failure in implementing the patient-returned medicines standard operating procedure (SOP) in the pharmacy.

My advice is to:

  • Ensure that all pharmacy team members, including locums, are fully aware of the patient-returned medicines SOP and are implementing it
  • Ensure that all waste medicines, patient-returned or expired pharmacy stock, are properly segregated and not left lying around in the pharmacy dispensing area
  • Ensure that the dispensing SOP is in place and being followed – in this incident, it is not clear if the final accuracy check was conducted properly or not, and who was responsible for the accuracy check
  • Use the NPA template essential SOPs for to help you to review and update your pharmacy SOPs if required

Example 2: MDS errors where medication were given to the wrong patient

  1. A prepared MDS was incorrectly dispensed to the wrong patient. It contained anti-diabetic medicines but the patient it was given to, did not have diabetes. The patient’s solicitors alleged the patient, who lived alone, took the medicines from the incorrect MDS and collapsed, before being found by a carer. The patient was admitted to the hospital and his solicitors allege he has been left with a significant cognitive brain injury. One of the issues identified has been the advance preparation of this MDS being stored in a stack with all other prepared trays on a shelf with the wrong tray selected to hand out to the patient.
  2. Another claim has resulted because a prepared MDS tray was allegedly given to the wrong patient. This incident also involved anti-diabetic medicines which was allegedly taken by the patient who did not have diabetes. Following a prolonged period of serious illness in the hospital, the patient died. Despite questions over causation issues, this has resulted in a claim against the pharmacy.
  3. Yet another claim involving MDS came about because a patient was administered medicines from the wrong MDS tray by a care company without making the proper checks. However, the care company is also asserting that the pharmacy supplied them with the wrong MDS tray which resulted in their error and are seeking to recover their outlay to the patient.

The MDS claims may have arisen because the MDS trays had been prepared in advance, stored in a stack on a shelf, and potentially proper processes not followed at the time of handing it over to the patient to ensure that the right tray was being given to the right patient. In the case of the care company example, such organisations also have a duty of care and must be able to demonstrate accountability to ensure that they have the right training and processes in place for their staff for managing medicines in care settings and administering them to patients.

LASA errors

Of the claims resulting from look-alike-sound-alike (LASA) errors, the most common errors currently resulting in claims involve the following two drug pairs:

  • Amlodipine / amitriptyline
  • Risperidone / ropinirole


In addition, I wanted to highlight a number of issues arising as a result of pharmacists not carrying out thorough record keeping; for example in instances when an emergency supply may have been refused (patient request or from a relevant healthcare practitioner)

It is advisable to make records of:

  • The date and time of the event
  • Patient, and practitioner details, if available and appropriate
  • Details of what the circumstances were, including details of the pharmacist involved as well as any other members of the pharmacy team present at the time
  • The pharmacist’s reasons for refusing the emergency supply
  • Advice given by the pharmacist and/or any other members of the pharmacy team, to the patient or representative or healthcare practitioner, as relevant
  • Details of signposting information provided
  • Any other details as relevant depending on the circumstances

If your pharmacy already has a procedure in place, it is advisable to check that all members of the pharmacy team are aware of the process and are implementing it, including any record-keeping requirements as detailed in the procedure.

The NPA Pharmacy referral and record keeping book can be used to help ensure when patients are referred to other healthcare professionals, appropriate records are kept and reason for referral is clear. It is also suitable for recording interventions for essential services and/or private services.

To order the Pharmacy referral and record keeping book, contact NPA Representing You on 0330 12300190.

Further reading and resources

For further information please contact the NPA Pharmacy Services team on 01727 891800 or email at: