The Pre-inquest Review for the dispensing mishap occurring in Chuk Yuen in early 2005 took place on May 18, 2007 and the judge asked for an adjournment until September 10, 2007 for the hearing at the Coroner¡¦s court for around 10 days. Apart from expert witnesses, there are witnesses which will include family members of the deceased, doctors who have attended the deceased, the defendant doctor¡¦s clinic nurses, Ex-employee and employee of drug supplier, pharmacists from the Department of Health, police constable dealing with the cases and a doctor from the Government laboratory. This will be less than 4 months ahead. There is the Professional belief that the pharmacists would fight fiercely for Separation of Prescribing from Dispensing of Drugs (SPD) this time and we should now prepare for a hard battle to protect our dispensing right.
In fact, as a response to the recent dispensing mishap in a private clinic involving isopropyl alcohol, the Hon Mr. Andrew Cheng asked the Administration on May 16, 2007 in the Legislative Council for any working plan on SPD. In his reply to the Legislative Council, our Secretary for Health, Welfare and Food stated that the occurrence of dispensing mishap is 1 to 2 reported case/s per year in private clinics in the past 3 years. I must say that we should aim at zero occurrences, but one to two out of more than 20,000,000 prescriptions per year in the private clinics is very little as compared with those from the pharmacists. To be realistic, human errors do occur no matter how careful you are. I agree there should be carefully worked out monitor mechanism able to plug the loopholes in dispensing error. Any reactive rule laying and regulation enforcement would only create a false sense of security in an attempt to achieve the goal of error avoidance.
The Secretary also informed the Legislative Council that ¡§¡KThe Code (Professional Code and Conduct for the Guidance of Registered Medical Practitioners) also requires medical practitioners to lay down appropriate procedures to ensure that the drugs are properly labeled and correctly dispensed, and follow the Good Dispensing Practice Manual issued by the Hong Kong Medical Association (HKMA). Medical practitioners must supervise the entire dispensing process and ensure that their staff comply with the procedures. The MCHK may consider taking disciplinary action against registered medical practitioners who are in breach of the above requirements. The HKMA is reviewing its Good Dispensing Practice Manual and will make appropriate changes to the manual where necessary¡K¡¨. ¡§.. We maintain an open mind on this matter (SPD)¡KAt this stage, we encourage members of the two professions to enhance their exchanges and cooperation on drug dispensing¡K¡¨
According to the Administration, SPD would not be realized in the near future. However, to make sure that the Medical Profession is a caring Profession, the Administration insisted that something must be done to revise the dispensing guidelines. As such, the Department of Health advocated further stringent control in the Good Dispensing Practice Manual issued by the HKMA (The Manual). Among the new measures suggested for second version of The Manual, there are four that arouse concern of our Union. They are as follows:-
1. The ordering of drugs from suppliers should be made in writing;
2. All medicines (not only external-use ones) should be stored in the manufacturer¡¦s original containers;
3. The mixing of different liquid medicines should be avoided in private clinics;
4. For the pre-pack medications, it is recommended to mark the expiry date and lot number on the bottle in addition to the name of the drug (For ease of tracing if dispensing error occur).
For drug ordering, verbal order is a norm among private doctors. The gist of the matter is to ensure the drugs ordered for a particular clinic are those intended and careful checking on the drugs ordered by the doctor himself is more than sufficient to serve the purpose. It would be extremely difficult to pour liquid medicine directly from a 3.6L container into each single small (e.g. 45/60cc) bottle and for the process to be repeated for each type of medication. It would suffice to avoid error in dispensing if steps are taken to ensure that relevant and correct information should be clearly marked on any intermediate containers. From my discussion with member colleagues in different CME study group functions, there is a consensus that mixing of different liquid medicines inside private clinics cannot be avoided. The avoidance of such practice may even introduce more errors in dispensing, not by the doctors, but by the caretakers for those paediatric patients. The dilution and mixing procedures have been established for the majority of private clinics and there is little known and documented incidence of adverse effect on the stability of medication so far. Should we shed our duty of safe dispensing to care takers of paediatric patients?
As I have said before in my message on Dispensing Right in Nov 2006 issue of HKDU Bulletin, we should tackle the problem wisely with the change of time. We should involve the community pharmacists as well, which is in line with the Authority. In what I have gathered from the draft code of practice for the community pharmacists, the community pharmacists are allowed to mix liquid medicines, switch bottles from the original ones and do not require written requests for drug ordering. Are we not trustworthy than they are in the art of dispensing? Are we, doctors, ¡§criminals¡¨ in the eyes of the public until proven otherwise? If not, why do we have to annually declare our no conviction before getting our annual practising certificate, which is not required in other professions in Hong Kong? Why should we agree on the recommendation to mark the lot number on the pre-pack medicine bottles in addition to the name of the drug for ease of tracing by the Department of Health if dispensing error does occur?
I have been in touch with a lot of you in various occasions recently and I do understand that these four suggested measures do stimulate your thinking on the way of future Safe Dispensing. So why don¡¦t you spell out your brilliant opinions and comments in the enclosed survey and let the authority understand the views of the profession in this matter. Would the public and the authority agree on mild changes in The Manual or more drastic ones? Or according to the feedback from some colleagues, why do we bother on such troubles and let¡¦s give them SPD straight away and even an action of SPD for one week in the whole of Hong Kong and to see what they want after all.
Dr. Yeung Chiu Fat Henry