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Another dangerous error

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The Pharmaceutical Journal Vol 264 No 7102p952
June 24, 2000 Letters


Another dangerous error

From Ms F. M. Bevan, MRPharmS, and Miss E. A. Davis, MRPharmS

SIR,-We would like to draw to the attention of the profession the extra diligence required when dispensing cytotoxic prescriptions. Further to the article "Reality and the law" (PJ, August 1, 1998, p145), we have had two incidents where potential fatalities could have occurred. In both, the drug involved was melphelan which had been prescribed on a discharge prescription with specific instructions not to continue. However, in both cases the drug was re-prescribed by the general practitioner for a continuing course. In one case the error was noticed by the patient before reaching the community pharmacist. Unfortunately, the other prescription was dispensed by a community pharmacist and the patient given a month's supply, despite the British National Formulary clearly stating that courses of four to six days every four to eight weeks should be prescribed. Fortunately, the patient's family queried the prescription with the hospital and no adverse event occurred.
If community pharmacy is to win the war of minds over doctor dispensing then we must be seen to be more able than doctors to protect patients from prescription errors. We would urge all community pharmacists to confirm prescriptions for unfamiliar cytotoxic drugs with the originating hospital pharmacy.

Fiona Bevan
Principal Pharmacist Clinical Services, Countess of Chester NHS Trust, Chester
Anne Davis
Senior Clinical Pharmacist, Haematology, Countess of Chester NHS Trust, Chester

Citation: The Pharmaceutical Journal URI: 20001946

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