Pharmacist’s Error Led To Patient Death

In the news last week, a pharmacist made an error which led to the death of the patient Read Here, this tragic news left me with extreme cold chills. I started a series of conversations with my network, discussing the main triggers of errors. It is clear no one is perfect, we are all susceptible to making errors. However, we need to constantly work on how to minimise and eradicate errors which in turn improves patient safety. Read along for points to consider during a shift. 


Think about possible ways to stay focus all day. The moment you lose focus an error is likely to occur. Take regular breaks. 

Keep Workstation Tidy:

My first lesson as a pre-registration student was to keep the workbench tidy ( I rolled my eyes).  A week later it made complete sense. Tidy workbenches and put split-boxes away.

Patient counselling:

Educating the patient on the drug being prescribed can significantly reduce error rate. It also provides the pharmacist another chance to review the drug dispensed. Use every opportunity to counsel patients.


  1. If you have a hint of doubt do not ignore it, chase it up.
  2. Contact the prescriber where appropriate.
  3. Review ways to improve yourself.
  4. Know your limits, do not put yourself under so much pressure.




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  • Anonymous
    December 13, 2016 at 10:57

    Be assertive and know your limit. Take regular breaks and review near miss logs as often as possible. Use your near miss log to guide you and your team, to learn from your mistakes.

    • Kaka Osagie
      December 13, 2016 at 14:03

      I completely agree. It’s very important to review near miss logs so as to learn from it.


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