The Pharmacy
15. Mrs A complains on 21 December 2023, the Pharmacy issued C a prescription for 40mg of propranolol (anxiety medication) instead of 10mg. This led to an accidental staggered overdose over a two-week period. C did not start taking this increased dose until March 2024, as they did not run out of medication until this time. Mrs A said she didn’t think to look at the dosage on the medication as she had no reason to believe the quantity was incorrect.
16. Due to being given the incorrect medication for two weeks, C felt dizzy and sick, they fainted and experienced migraines. C explained when they attended the ED following the overdose, doctors told them they were lucky their body had not shut down at all, and they were days away from renal failure. We appreciate this must have been a very difficult time for C.
17. In its response, the Pharmacy explained the packaging of propranolol 10mg and 40mg are very similar, and as the two strengths are stored side by side on the shelf, the incorrect boxes were selected in this instance. It explained the medication was dispensed and checked during the penultimate days before the Christmas closure, and the pharmacy was exceptionally busy. This unfortunately resulted in human error, during a very busy time of year.
18. There is no mention of renal failure in the ED notes from C's attendance on 20 March 2024.
19. Their observations recorded during this attendance were stable. Instead of 40mg Propranolol in divided doses, C was taking 160mg a day. The attending clinician noted the toxic dose to be 270mg and that C was taking medication below the toxic dose. There were no ECG changes. Toxbase guidance was reviewed and following assessment on finding no features of clinical concern as per Toxbase, the ED consultant discharged C back to the care of the GP.
20. Our adviser explained on review of the ED records, there is no suggestion of a lasting impact of the staggered overdose on C. The management was satisfactory, no acute abnormality was found on assessment. The ED safety netted and discharged C.
21. We requested a copy of the action plan the Pharmacy had created because of the error it had made. The Pharmacy made the following actions as a result:
• the strengths of propranolol have been separated on the shelf to reduce picking errors • the staff involved in the error were identified and the accuracy checker in question took a step back from their checking role • the training providers manual for the accuracy checkers qualification was consulted, and instructions were followed on how to handle such an error. This resulted in a 200 item firewall check whereby all items checked by the accuracy checker were subsequently checked by the responsible pharmacist prior to bagging • this incident was reported to the training provider and formed part of the accuracy checkers revalidation process • the incident was reported to C’s GP, on the day the error was discovered. The incident was also reported to the superintendent pharmacist • the incident has been filed in the pharmacy incidents folder and reported online • the pharmacy had been in contact with Mrs A via telephone call on several occasions and left voicemails when the calls have not been answered. There have also been emails between the pharmacy and Mrs A • a staff meeting was held when the error was discovered.
22. Our Principles for Remedy say remedial action can be an apology, explanation, and acknowledgement of responsibility. Our principles also say revising procedures to prevent the same thing happening again, giving learning and training to staff are appropriate remedies when things have gone wrong.
23. We consider these actions are proportionate to remedy the distress caused to C and Mrs A (distress for C of around two weeks whilst they were taking the increased medication). Whilst this experience would have been very scary for C at the time they were feeling unwell, there was no lasting impact on their health. The action plan highlights the Pharmacy has taken the error very seriously and has put several service improvements in place to prevent this error from happening again.
24. Therefore, we will take no further action.
The Practice
25. Mrs A complains the Practice did not arrange an urgent GP appointment for C on 20 March when they were experiencing symptoms because of the propranolol overdose.
26. In its response, the Practice explained the receptionist correctly instructed Mrs A to contact NHS 111 for advice as it did not have any appointments available. It explained the practice has adopted the British Medical Associations (BMA) Safe Working Guidance which is designed to keep clinicians’ work at safe levels throughout the day and thus ensure patient safety. When Mrs A telephoned, it had already reached its safe working limit.
27. BMA guidance on safe working states:
• ‘Practices are obliged by their GMS contract to provide for the reasonable needs of their patients and for the assessment of urgent problems arising in their patients in their practice area. Emergency or urgent problems can be directed to emergency departments, 999, or 111. Patients that can wait should, following assessment, be placed on the waiting list if safe capacity for appointments is exceeded for the day.’
28. We consider the Practice acted in line with the above guidance. It was at capacity for same day appointments so in line with the guidance the Practice advised Mrs A to contact 111 on C’s behalf. Mrs A contacted 111, and then A was able to attend the ED the same day. In considering this, we have not found any indications of failings for this complaint component.
29. We hope Mrs A can be reassured we have taken her concerns seriously.