Checking an item you also dispensed: accuracy checks under pressure

Introduction

The final accuracy check is often the last barrier between a dispensing error and a patient. It works because a second person looks with fresh eyes. This scenario looks at what happens when pressure squeezes that second person out.

What happened?

An accuracy checking pharmacy technician was working a late shift in a hospital dispensary. A ward rang three times about a discharge prescription that was holding up a bed. The only other dispenser had gone to the wards.

The prescription had been clinically screened by a pharmacist. The technician dispensed the items herself to save time and then carried out the final accuracy check on her own work. The pharmacy's SOP said that the person who dispenses an item must not be the person who accuracy checks it.

One item, a beta blocker, was dispensed in the wrong strength. The boxes looked alike and were next to each other on the shelf. A ward nurse noticed the difference against the discharge letter before the patient went home. The patient was not harmed.

What was the concern?

• An independent check was skipped. People tend to see what they expect to see when checking their own work, so self-checking is much less likely to catch an error.
• The technician worked outside the SOP that sets the limits of her accuracy checking role.
• The decision was made alone. Nobody with authority to change the process was asked.
• The error reached the ward. It was caught by chance, not by the system.

What was the outcome?

In this scenario the technician reported the incident herself as soon as the ward phoned. The pharmacy carried out an incident review that looked at the whole system: staffing on late shifts, how look-alike packs were stored, and how urgent discharges were escalated. The technician wrote a reflective account and completed a refresher on the checking SOP. The two strengths were separated on the shelf.

The review treated this as a learning event. It also made clear that stepping outside an SOP is a decision for the responsible pharmacist, not for an individual under pressure.

What can we learn?

1. A check only works if it is independent. If you dispensed it, someone else checks it.
2. Your accuracy checking authorisation is defined by your SOPs. Know exactly what they allow.
3. When the process cannot be followed, stop and escalate to the pharmacist. A short delay is safer than an unchecked item.
4. Pressure from the ward is real, but it is information to pass on, not an instruction to cut corners.
5. Report errors and near misses straight away. Early, honest reporting is what good professionals do, and it is how systems get fixed.
6. Look-alike packs are a system problem. Flag them.

Relevant pharmacy practice

Accuracy checking technicians carry out the final accuracy check on items that a pharmacist has already clinically checked, within limits set by their employer's SOPs and their own training. A common and important limit is that they do not check items they have dispensed themselves.

Relevant GPhC standards for pharmacy professionals include Standard 5 (use professional judgement), Standard 8 (speak up when they have concerns or when things go wrong) and Standard 9 (demonstrate leadership).

PPets learning connection

Dispensing accuracy, error reporting and working within SOPs are covered in the Level 3 Diploma for pharmacy technicians. This scenario can support a reflective account on professional judgement under pressure.

Record this as CPD

Registered pharmacy technicians can use this article towards GPhC revalidation, as an unplanned CPD entry or as the starting point for a reflective account. Pharmacy assistants and trainees can use it as evidence of reflective practice. Note down three things:

1. What you learned from this article
2. How you have applied it, or will apply it, in your own role
3. The benefit to the people who use your pharmacy's services

Sources and further reading

• GPhC pharmacy team toolkit: learning from incidents
• GPhC standards for pharmacy professionals

Related from PPets

• Level 3 Diploma for pharmacy technicians
• How to become a pharmacy technician

This article is for general educational purposes only. It is not legal advice, professional regulatory advice or clinical advice about an individual patient. Always follow your pharmacy's SOPs and check current official guidance and product information.

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