A West Midlands pharmacist has been reprimanded by the Statutory Committee after he had dispensed adrenaline ampoules to an addict instead of methadone. The patient, who had suffered side effects after he injected one of the ampoules intravenously, had not been advised to seek medical attention.

When it met on 9 December 2003, the committee inquired into the case of John David Bryant, of 9 White House Green, Solihull, West Midlands. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that on 11 October 2002, while locum pharmacist in charge of Brights Chemist, 1 Middlemore Road, Northfield, Birmingham, Mr Bryant had dispensed in error three ampoules of 0.5ml adrenaline injection BP 1 in 1000, labelled as methadone, on a prescription calling for three methadone BP ampoules 50mg/ml It was also alleged that Mr Bryant had failed to advise the patient concerned to seek immediate medical advice after he had injected one of the ampoules; that he had failed to advise the patient’s father that his son should seek immediate medical advice; and had failed to contact the patient’s doctor or drug addiction clinic, or the superintendent pharmacist of Brights Chemist.

Geoff Hudson, of Penningtons (solicitors) appeared at the meeting to present to give the facts of the case.

Mr Bryant, who was present at the inquiry, represented himself.

The committee heard that the patient to whom the adrenaline ampoules had been erroneously dispensed was an addict; he had administered one ampoule to himself intravenously shortly after it had been dispensed. Almost immediately, he had felt great pressure in his head, his heart began to race and he had been unable to control his hands. He had returned to pharmacy in a state of distress, told Mr Bryant what had happened and returned the unused ampoules of adrenaline.

Mr Bryant had assured the patient that he would be “all right” so long as he took no other medication for four hours. He did not, however, advise him to seek medical advice. Nor did he contact the addiction clinic that had issued the prescription, the patient’s doctor, the pharmacy manager or superintendent pharmacist. When the patient’s father had visited the pharmacy later the same day, he had not suggested that medical attention should be sought.

The patient himself saw his doctor on 14 October, when his blood pressure and heart rate were found to be very high. He was advised to attend the local hospital accident and emergency unit.

A trainee dispensing technician at the pharmacy had been sufficiently concerned that Mr Bryant had not informed the branch manager that she sent a text message alerting her to the incident and made an entry in the error book.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that Mr Bryant, who had been a pharmacist for “44 distinguished years” had not tried to excuse his error.

The original error had been that the adrenaline ampoules had been put in the Controlled Drugs cabinet and then put in a bag for the patient. Nevertheless, said the chairman, Mr Bryant had not checked what was in the ampoules, only that there were three of them and they were not damaged.

When the patient returned to the pharmacy after having injected one of the ampoules, Mr Bryant had appreciated immediately what had happened. He had then decided, erroneously, after observing the patient and concluding that his symptoms were subsiding, that he should simply advise him to lie down and take none of his other medication.

Mr Bryant had consulted the British National Formulary, where it stated in relation to adrenaline/epinephrine “IMPORTANT. Intravenous route should be used with extreme care”. It was odd, continued Lord Fraser, that having looked that up he had not then advised the patient to seek medical advice.

The dispensing error had been compounded by Mr Bryant’s failure to advise and inform, said the chairman. That amounted to misconduct such as to render him unfit to be on the register. However, Mr Bryant had been open and frank with the committee and had now retired from practice.

The committee reprimanded Mr Bryant.

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customer to pharmacy “could you tell me if there’s something cheaper and better than this?”

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BUFFALO, N.Y. — University at Buffalo pharmacy student Brian Olney didn’t expect to save anyone’s life when he reported to his internship job one Friday last month.

As a fourth-year student in UB’s six-year doctor of pharmacy program, Olney spends 20 hours per week during the school year in a Wegmans pharmacy to fulfill requirements for his pharmacy degree.

His duties include filling prescriptions under the pharmacist’s supervision, answering customers’ questions and assisting them in selecting over-the-counter medicines.

But on this particular day, Olney would give one customer advice that may have meant the difference between life and death.

The conversation began the way many do: an older woman came up to the counter and asked Olney what over-the-counter medicine he would recommend for a bad headache.

Instead of simply directing her to the aisle where acetominophen or ibuprofen are kept, Olney asked her about her headache.

“We had just finished our neurology unit in school and all of this stuff was fresh in my head,” he recalled. “I came out from behind the counter and asked her what type of headache it was. She told me it felt like the worst headache she’d ever had.”

That statement alone was enough to make Olney believe that what she was talking about was much more serious than an average, garden-variety headache.

“It clued me in right there,” he said. “That’s when I started asking more questions.”

He asked her to describe the onset of the headache. She told him she had been sitting down, watching television, when it hit her all of a sudden.

“Those two things — that it was the worst headache she’d ever had and that it hit all of a sudden — made me suspect right away that either it was a blood vessel that had burst or a stroke,” he said.

Olney explained that he had learned that if left untreated, either of these conditions can kill.

While trying not to alarm her, he told her that she needed to see her doctor right away.

He spoke with her for a few more minutes, explaining to her why her symptoms were more serious than she originally had believed. The customer was surprised, but followed his advice.

Olney didn’t hear anything more about her until about a week later. He was working at the counter again when another woman came up and asked if he was Brian.

“I said I was and she said, ‘Well, I want to thank you.’ I said, ‘For what’?”

It turned out that it had been her mother who had come to Olney asking about headache medications; luckily, she had taken his advice and gone directly to her doctor, who sent her immediately to a hospital emergency room.

There, Olney’s initial suspicion was proved correct. The woman had suffered a subarachnoid hemorrhage — a burst blood vessel — but because she had sought treatment early, physicians at the hospital were able to treat the condition with medication and supportive care. After a few days in the hospital, the woman was able to return home and is making a good recovery.

“It wasn’t like I was trying to do anything heroic,” said Olney, “but I was just trying to focus on what we could do for her. She wasn’t going to go to her doctor just for a headache, but if she had let it go just another day, that could have been it.”

Olney credited the UB doctoral program, which has a strong emphasis on disease-state management, with giving him the knowledge that allowed him to make the proper recommendation.

“If we didn’t have the opportunity to go through a neurology unit and to learn and notice the warning signs, then maybe I would have said, ‘Take some Tylenol,’” he said.

And, according to Wayne K. Anderson, Ph.D., dean of the UB School of Pharmacy, stories like Olney’s are not unique.

“There are hundreds of these stories that can be told by pharmacists and pharmacy students everywhere,” Anderson said. “In fact, I doubt you could find a pharmacy in Buffalo that doesn’t have a story like this one.”

As for Olney, he now has a renewed enthusiasm and appreciation for the profession he will enter when he graduates in 2001.

“It’s incredible; look at the change we can make in one person’s life,” he said.

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I just had a doctor prescribe a pt lidocaine patch to be used continuously over 24hours. Actually, it’s to be taken off only 1hr/day. I thought lidocaine was to be used as 12-on-12-off?

Anyone shed some light on this?

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