Double check?


I was faced with an interesting scenario whilst locuming on Saturday. A lady came in to collect a diamorphine ampoule prescription which contained  three different strengths. It had already been made up and was in the CD cupboard. All I had to do was check for ID and hand it out.

But I did not. Something inside me made me open it to double-check and I am glad I did. I do not make a habit of opening prescriptions that have already been checked before handing them out. However, I thought that I would also be liable if it was wrong as I was the responsible pharmacist on duty.

All three strengths had been labelled ‘Use as directed’ and there was a dose stated on the prescription. So I decided to relabel it with the dosage.

Was that the right thing to do? 

Should I have even opened the bag?

I left a note for the manager.

Please let me know what you think

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8 thoughts on “Double check?

  1. Generally do not ‘re-check’ bagged scripts, but do make an exception with CDs. Why? I do it, but it does not make sense. As the RP, you are accountable for everything that goes out during your shift, irrespective of who actually assembled & checked. ‘Re-checking’ every bag that had been made up previously, borders on the impossible. So we rely on the integrity of pharmacists before us and pray for the rest. After many years of experience as pharmacist, I do not have a workable, practical solution to this issue. There, but for the grace of god, go I!

  2. Personaly as a patient/customer I would always be pleased to wait that bit longer for someone re-checking my dosage and instructions on my medication, although not distrusting our Pharmacist I think it is also important for us to also check our own medication for mistakes before taking it.

  3. I think you did the right thing. Obviously very lucky to think about re-opening a checked prescription bag. Not many of us would do that for many simple reasons such as lack of time and we are always too busy etc.

    However, what we do in our work company is put the CD item in a see-through sealed bag with patient bag label on, so that before it goes out to the patient it is ALWAYS double-checked no matter which pharmacist is working as responsible pharmacist or not.

    This simple procedure could be an improvement and solution to those who might have issues?

    – Just my opinion.

  4. Yes I also work part time for a company who keep CDs and fridge items in clear bags. When I Locum, I generally tend to leave the dispensed item with the script in a basket in the CD cupboard because I believe the Pharmacist who will be RP when its handed out will probably want to glance at it before they hand it out, only do this with CDs though. So you did the right thing in my opnion.

  5. In my company we are meant to do a ‘3rd check’ before handing medication out. This involves looking inside bags which have been checked. It is difficult to do this all the time, but I defo do it when it comes to CDs and fridge lines. You did the right thing my friend.

  6. I would not open the bag in first instance as the person who got the medicine ready and bagged means its been checked and it is ready to go. There could be reasons as to why a pharmacist let the dose be MDU however, law doesn’t permit MDU , it can be one to be given/taken (tabs etc) as before …
    On one hand u made the supply lawful by correct labelling however, whoever made it ready would be responsible for it even if u gave it out. I have learned that never ever ignore the gut instincts , they always direct you to right thing. So, I’d say you did the right thing.

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