Once bitten

A 25-year-old patient visited her GP with infected insect bites and was prescribed antibiotics by computer generated prescription. The practice dispensary issued the tablets, to be taken four times a day. Two days later the patient was admitted to hospital following a car accident in which she sustained a fractured lower leg.

The casualty officer asked the patient if she was taking any medication, and discovered that she had been issued fluoxetine 20 mg tablets instead of flucloxacillin 250 mg tablets. The patient had taken five tablets in total. The GP was alerted to the error that she had made and telephoned the MDU for advice.

MDU Advice

The member was advised to offer the patient an apology and a full explanation. She was referred to paragraphs 30 and 31 of the GMC’s Good Medical Practice guidance which clearly states that doctors “must act immediately to put matters right” if a patient under their care suffers harm or distress, and also states that patients who complain about the treatment they receive “have a right to expect a prompt, open, constructive and honest response including an explanation”.

The Outcome

The patient made a claim against the member. Expert evidence obtained by the MDU suggested that the patient’s reaction time might have been slowed by the quantity of antidepressant medication that she had taken in error. The claim was settled on behalf of the GPs who were vicariously liable for the actions of the practice dispenser. Following the incident the practice carried out a significant event audit.
The audit revealed that a couple of factors had contributed to the mistake. Not only did the tablets have similar sounding names, but they were located next to each other on the dispensary shelves. The practice amended its prescribing and dispensing protocols to ensure that a similar error did not occur in future.

This page was correct at publication on 01/05/2009. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.