38 Wrong dispensing - takes a life

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I was sitting in my friend's house when suddenly the title "Chemist hands out wrong drug; 65 year old dies" in Bangalore Mirror dated May 3 2011 caught my eyes. I was shaken up. The issue was a chemist had dispensed (rather sold) METHOTRXATE - an anti cancer drug on a prescription for Met XL 50 a anti-hypertensive drug. The patient is reported to have developed rashes, started feeling uneasy and died in a hospital. The paper has raised certain queries? How under-qualified pharmacy staff is responsible for such fatal goof-ups? The paper quotes Mr Prasad davane , General Secretary of Retail and dispensing chemists Association as having said that illegible prescription used to be the cause for such mistakes in the past and the prescription in this case was very much legible and there was no scope for confusion / mess up that happens sometimes due to look alike / sound-alike drugs. One of the biggest problem we have been trying to address within the fraternity is that qualified pharmacist should be present at the store and only such pharmacist should dispense medicines, says Mr Prasad. The news item has given a prescription to the pharmacists also: 1. As per the code of ethics Regulation 2002, every doctor must put his full name and registration number on the prescription. 2. Chemists must issue a bill for every medicine that he dispenses 3. Only a qualified pharmacist should dispense medicines 4. If the prescription is not legible the chemist must not assume the name of the drug, instead must either call up the doctor or send the prescription back and get the drugs written in neat handwriting to avoid confusion. I would add further: 5. The prescription should carry the contact number of the doctor and his / her schedule of availability with location. 6. The prescription should carry disease complaints and diagnosis. Well, a life is lost. A family has died. The news item has gone into the old paper mart or for package along with the news. Has anyone at the top or key position got the message to act upon? Can we see and feel the action to prevent the recurrence?

About the Author

Ph. Bhagavan P S RPh's picture

I am Bhagavan ,Rtd. Dy Dir.(Pharmacy),Govt of Karnataka, India and currently serving as Registrar, KSPC, Bengaluru, India . I love to write on Hospital pharmacy series related topics out of my experience and observations. Check out my Pharmacist in the Hospital.


Amol Dhiaman's picture

Sir you have provided a very healthy and helpful information. Even i think that this information should be labelled or posted in all the hospitals, dispenseries or pharmacies in order to assure the healthy well being and care of all individuals. Thanks a lot. With Regards Amol Dhiman Team GLORY

Amol Dhiaman

Bhupendra's picture

Dear Sir, It is unfortunate that a life is lost. In my opinion the prescription wasn't dispensed by pharmacist himself. Instead it has been dispensed by Pharmacy Assistant (Who is not more that 10 th class pass). It is very necessary now to appoint pharmacy inspectors in all the states. And this appointment should be practical it means that Pharmacy Inspector should visit the pharmacies regularly. Sir I would like to add one more point 7. The prescription should wear the sign and registration number of pharmacist who is dispensing the medicines along with seal.

General Secretary Indian Pharmacist Association (IPA) http://www.ipa.medlineindia.com

Sravani kompella's picture

Its really a heart throbbing situation sir.. But i think even qualified pharmacists do the mistake at times..so i feel that doctors who are prescribing should write even the active drug along with the trade name which may eliminate certain mistakes...

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