Who is responsible?

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When a prescription is dispensed, the Pharmacy Board expects that the pharmacist responsible for the script can be identified.

It is common practice in many dispensaries to have multiple pharmacists involved in the dispensing of a single item. One pharmacist or technician may input the information, another may assemble the prescription, while a third could do the final check and clear the script for collection. In this scenario, the initials of the pharmacist entered into the computer originally will not necessarily reflect who does the final check and is therefore responsible for the dispensing.

Case Scenario

Recently, a busy pharmacy made a dispensing error whereby Carbimazole was provided on a script that called for Carbamazepine. This error is unfortunately relatively common and has been the subject of past PDL practice alerts. In this particular case, the consumer suffered physically and filed a complaint with AHPRA who investigated. The pharmacist named in the complaint stated that he believed he was not responsible for releasing the script and in fact it could not accurately be determined who had given the final clearance.

As a result of this failure to identify the dispenser, AHPRA investigated the pharmacy owners in addition to the employee pharmacists, as they had ultimate responsibility to oversee all practices and protocols in their pharmacy.


Traditionally, the initials in the computer were deemed to be the person responsible for the dispensing. However, with the advent of ‘team dispensing’, the initials alone cannot be relied upon.

A possible solution to this problem is to have the pharmacist doing the final check initial the dispensing label on the product to identify themselves. Though this alone is not error proof as the packing with the attached label can be removed or discarded when the product is finished.

Another way to identify the responsible pharmacist is to initial the computer sticker placed on the actual prescription, or duplicate, which can be retained by the pharmacy and accessed at a later date if required.

No one process of identification is stipulated but all pharmacies must have clear protocols in place to satisfy the need to identify the dispenser.

For immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7, Australia-wide.