Dispensing error improves a patient's health

It's a topical subject in the week that a London pharmacist was given a suspended jail sentence for being the pharmacist in charge of a pharmacy where a dispensing error occured and whilst the coroner ruled that the taking of some tablets which were dispensed in error did not contribute to the patient's death, the pharmacist was nevertheless prosecuted, I came accross a story of where a dispensing error improved a patient's health and well-being.

The story goes that a patient who always used the same pharmacy had been refused a repeat prescription by their surgery on the grounds that they should still have another month's medication. The patient insisted they had run out of the medication and further discussion led to the suggestion that at the time of dispensing, a dose reduction to half the previous dose had been made on the prescription, but missed whilst dispensing and the former dose had been repeated from the pateint medication record.

The surgery had reported the incident to the pharmacy, who verified that the medication had been incorrectly labelled at the former dose. Meanwhile, the patient was checked out by the doctor, who carried out blood tests and examination of the patient. The doctor's conclusion was that the patient was far better on the higher dose of medication, despite the dispensing error, and forthwith the patient was to remain on the higher dose after all.

The patient declared themselves very happy with the outcome and even thanked the pharmacist concerned for their error, which had resulted in an improvement in their wellbeing. This is a true story. The circumstances have been left vague to protect identities of all concerned.

Should the pharmacist be prosecuted, jailed, fined or given a pat on the back? As many a collegaue has echoed their feelings this week, there but for the grace of God go I.