JS is a 32-year-old man and a regular methadone patient. You have a good relationship with him, and he is respectful. It is Friday evening, and you dispense take-home doses for the weekend as usual in accordance with his MDA script, which has come to an end.
Shortly after JS has left with the extra doses, you notice that the prescription is incorrect: the date given to supply the take-home dose is February 28, while today is February 18. Given JS has been following the same prescribing pattern for several months, this is presumably a mistake. However, you are unable to contact the substance misuse team.
What should you do? What are the implications of the error for you, the pharmacy, and JS? What would happen if JS used the extra doses to overdose?
Where does the law stand?
The provision of methadone services can be time-consuming and imposes administrative burdens beyond those for non-controlled drug supplies, not least because supplies are usually made on a weekly or even daily basis. These extra burdens mean that it is, unfortunately, not uncommon for errors such as the one described in this scenario to occur. Other issues that we often encounter in relation to the supply of methadone to patients include a failure to record supplies to and from the pharmacy in the CD register and supplying instalments on the wrong date.
Regulation 16(1)(d) of the Misuse of Drugs Regulations 2001 provides that a pharmacist must not supply medication pursuant to a controlled drugs prescription before the date specified on the prescription. Supply of a controlled drug before the appropriate date is a criminal offence, although prosecutions for isolated incidents are relatively rare even where the police do investigate (and the police investigate possible controlled drugs offences much less now than they did a few years ago). It is more common for these issues to be investigated by a PCT and/or the General Pharmaceutical Council, although formal disciplinary action for an isolated incident such as this should be considered unlikely.
In this scenario the pharmacist should consider taking a number of steps to mitigate the error, including contacting the patient to try to persuade him to return the medication (this may be difficult if it will leave the patient without any methadone over the weekend), notifying the substance misuse team of the error as soon as possible and notifying the PCT's accountable officer. The pharmacist would also be well advised to review the pharmacy's Standard Operating Procedures (SOP) to make sure that a date check of the prescription is part of the controlled drug SOP. All staff involved in the dispensing and supply should be reminded of the contents of the SOP and the legal requirements for a valid CD prescription. If the patient does take an overdose, the pharmacist should check the terms of his professional indemnity insurance to see whether the possibility of a claim needs to be notified to insurers.
The pharmacist should make a note in the PMR and the pharmacy's incident report log of the incident and the action taken. It is much less likely that there will be serious repercussions from any incident if the pharmacist can show good clinical governance.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
