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Stressed, self-checking pharmacists must be bold and temporarily close their pharmacies

In November 2019, The Pharmaceutical Journal wrote that “almost half of community pharmacists admit to self-checking their own dispensing” (Pharm J 2019;303[7931]:294). This dismayed me.

When I practised, self-checking seldom occurred; when it did, it mostly resulted from lack of staff or time. Practice was sometimes so stressful that, when near my wits’ end, I would go and “hide” in the toilet — the only place where I could snatch five minutes of recovery. Nevertheless, the backlog had piled up by my return.

Everyone, being human, makes errors. Double-checking reduces the risk of an error. Simple statistics quantify this risk: for example, if the dispenser makes 1 error in every 100 items, the risk of occurring on each dispensed item is 1/100. Suppose the risk of a checker making an error is also 1/100. The risk of both making the same error about the same dispensing is 1/100 multiplied by 1/100 — 1 error in 10,000 (1/10,000). This may be over-simplistic — if your work is not checked, you may be even more careful.

The double-check is a powerful safety technique. Another person may instantly see something to which you are blind. Witness the double-check before amputating a left or right leg, and a quadruple check on certain crucial components before space missions.

Now sometimes a patient rather than a pharmacist, I check that my prescription label includes “dispensed by” and “checked by” boxes, and that they appear to be initialled by different individuals. And I always check that I appear to have received what I expected, as far as I can tell. Of course, practising (or retired) healthcare professionals make terrible patients.

If you find yourself in a situation where you are struggling to cope, reassure yourself that it is not your fault. It is the system. For the good of the patients, the system should be changed. All manner of reasons could have enabled such a dangerous system to exist — one is greed.

There are many constraints on today’s pharmacists. Remember that, as the healthcare professional in charge, you retain some power, which includes the ability to exercise an extreme option (which you may wish to discuss with your employer, trade union and/or insurance company) — walk out, so that the pharmacy may then close.


Malcolm E Brown, retired pharmacist

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2020.20207604

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