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Dispensing error management — GPhC CRA MCQ

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EasyPharmacy LawDispensing error managementGPhC CRA

A pharmacist discovers that a locum dispenser made an error two weeks ago, dispensing amitriptyline 50 mg tablets instead of the prescribed amlodipine 5 mg tablets to a patient. The patient has been taking the wrong medication. What is the most appropriate immediate action?

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Correct answer: E — Contact the patient immediately to stop taking the amitriptyline and arrange for the correct medication to be supplied

Patient safety is the immediate priority. The patient must be contacted urgently to stop taking the wrong medication and to assess whether any harm has occurred. Amitriptyline at 50 mg could cause significant adverse effects including drowsiness, anticholinergic effects, and cardiac conduction abnormalities. The correct medication should be supplied immediately. Following the immediate patient safety actions, the error should be documented, reported, investigated, and appropriate learning implemented.

Reference: GPhC Standards for Pharmacy Professionals; MEP