Pharmacist ~ Pharmacy ~ Multiple
medications ~ Multiple prescriptions ~ Stacker trays ~ Standard
operating procedures ~ Professional standards ~ Right 4(2)
A 78-year-old woman who was on multiple long-term prescription
medications was discharged from hospital with a prescription for
additional medications. The woman and her caregivers were concerned
that she might not be able to manage taking 12 different
medications at different times of the day.
A neighbour, who was a nurse, asked the local pharmacy if the
medications could be dispensed in blister packs. While the pharmacy
was unable to do this, the pharmacist offered to dispense the
medication in stacker-trays. Stacker-trays are plastic containers
which each have eight trays: seven are marked with the days of the
week, the eighth being an unmarked spare tray. Each tray is further
divided into four compartments labelled morning, noon, evening and
night. The labelling and compartments help patients to identify the
medications they are required to take at a particular time of the
The pharmacist offered to sort the woman's existing medicines,
and those to be dispensed that day, into the trays. The neighbour
dropped off the medicines and the new prescriptions. When she
collected them, however, she noticed that the pharmacist had
omitted one medicine from the evening intake and had doubled
another. The medicine to be taken that evening had been placed in a
paper bag, which was incorrectly marked as the morning dose.
As the errors were discovered before the stacker-trays were
delivered to the woman, she was not adversely affected. The
pharmacist corrected the error, notified the woman's GP of the
error, apologised to the woman and her doctor, and reviewed the
pharmacy's dispensing and checking systems.
It was held that the pharmacist's failure to follow his usual
practice and the pharmacy's standard operating procedures was a
breach of Right 4(2).