Dáil Éireann debate -
Tuesday, 10 Nov 1970

Vol. 249 No. 6

Adjournment Debate: Public Health Dispensaries.

Dr. O'Connell

I must confess I was hesitant about raising this matter on the Adjournment but it is of great importance, constituting as it does a problem that concerns many people. I asked the Minister for Health in my question today if he was aware of hazards to patients in the matter of present dispensing practices in public health dispensaries and what action he can take in this regard. The Minister can only be informed by his experts and obviously they were not aware of the fact that the practice in dispensaries is such that when patients receive a number of different tablets they are in danger of either being overtreated with one type of tablet or, in other cases, of not receiving proper treatment.

I investigated this matter and consulted with dispensary doctors. I found that bulk buying occurs in central pharmacies of the Dublin and other health authorities throughout the country. The stocks come in large containers and the tablets generally are unmarked. One dispensary doctor told me that the containers have labels that can quite easily fall off, with the result it is impossible to know what type of tablets are in the containers. Another doctor told me that on one occasion he found that a tin was labelled as containing tablets for the treatment of heart condition, but when he took the lid off the leaflet inside stated that the tablets were tranquillisers. Needless to say, he was astonished. Another dispensary doctor told me he had prescribed heart tablets for a patient; the tablets were to be taken three times a day and, in addition, he ordered the patient to take a sleeping tablet at night time. The tablets were dispensed in identical boxes, the lids of which can be easily transposed, with the result that the patient could quite easily make a mistake and take the wrong tablets. On one occasion when this occurred the patient was almost comatose, and but for the fact that his condition was recognised at an early stage he would have died.

This problem cannot arise when the patient is receiving only one type of tablet; it only happens when a patient is on a number of different tablets, perhaps for nerves or tablets for sleeping or for heart condition. However, the fact that the tablets are dispensed in these containers, whose lids can be so easily transposed, constitutes a grave hazard to the health of the patient. I would not have made my statement originally but for the fact that I was personally involved in a case where the patient almost died. I investigated the matter and then brought it to the attention of the Minister for Health.

The other point which I brought to the attention of the Minister was the fact that these unmarked tablets purchased in bulk are a great danger. We can all appreciate that the slightest error in the packing of unmarked tablets can result in death. I mentioned that unmarked tablets should be banned. I asked for this action following my investigation and I know some reputable drug companies are instituting a code or some form of marking that will identify immediately the various tablets. I regard this as absolutely essential.

We should abolish the dispensing of these tablets in pill boxes. We should resort to the method employed by retail pharmacists, whereby the tablets are dispensed in proper containers. The containers have a code number that immediately identifies them and this would be of great help in any case where the doctor might be suspicious or where renewal of tablets is required. Each retail pharmacist has a prescription book in which he enters the full details of the prescription; this is coded and the code number appears on the bottle of tablets. I know dispensary pharmacists are overworked and I realise their problems, but this is no justification for ignoring the fact that dangerous tablets are being dispensed to patients without adequate precautions. We do not know what illnesses or deaths may have occurred as a result.

I have personal knowledge of cases where patients were almost comatose as a result of taking the wrong tablets. However, I shall not dwell on this because I am sure the Minister appreciates the problem and I have no doubt that he will take some action in the near future. Therefore, I shall say no more on this subject.

Mr. L'Estrange

I should like to say a few words on this subject. I came in contact with this problem about two years ago in Mullingar and I raised the question at a consultative health committee meeting. I was called in one Sunday afternoon by the wife of the person who was ill. While I was there she showed me ten boxes containing different tablets—all the boxes were identical. While I was in the house she took the lid off the boxes of tablets and put them back on the wrong boxes. In this case the patient had been prescribed sleeping tablets and also tablets for a heart condition. I questioned the woman to know if this had happened before but she became confused and said she did not know. Immediately afterwards I went to the doctor and complained about this matter. The patient was brought to hospital that evening and he died less than a week afterwards. I do not want to say that anyone was to blame in this case because the dispensing of pills in such a manner seems to have been the method that has been used during many years.

Deputy O'Connell has some of the boxes with him now and we can see that they are identical and it is very easy to make a mistake. Could it not be arranged that different coloured containers would be used for various tablets—say red boxes for sleeping tablets, heart tablets in blue boxes and so on? I agree with Deputy O'Connell that something should be done and the sooner the better. The present Minister for Health has certainly tried to be very helpful. He appears to be a man who is devoted to his duty and he seems to be making a success of his job.

While this problem may appear to be a minor matter to some people it is important and should be attended to without delay. It is not uncommon for people to have five or six different types of tablets in identical containers and in the case I mentioned the woman had ten containers which were practically identical. In the case I have mentioned I think it can be said that the patient died because somebody had mixed up the different tablets.

Minister for Health (Mr. Childers)

First, as I said earlier today, I hope the scheme for the provision of drugs to medical cardholders and others qualified to obtain them will be changed and will be superseded next year by a scheme providing for the supply of drugs through retail chemists. Secondly, I am interested in the observations of Deputy O'Connell and of Deputy L'Estrange because I did take the trouble to inquire about this. There are virtually no complaints whatever in my Department arising either from doctors or from patients or from the public in general that patients have suffered through taking the wrong drug as a result of the marking system. That does not mean we ought not to investigate the matter further. I should like to deal with the points seriatim.

There is the question of the practice of local government bulk-buying of unmarked tablets and of these being sent to public health authority pharmacies in improperly labelled containers. We are aware of only one instance, which occurred several years ago, where a particular firm are alleged to have incorrectly labelled a container of drugs, and this was never proved. Then there has been a suggestion that unmarked drugs supplied to public health pharmacies come in containers with labels which too often become detached. We have had no complaints about this. I have inquired from the Department's pharmacists and the chief pharmacist to the Dublin Health Authority, and they are not aware that labels become detached, so the statement which was made in the Irish Medical Times seems to require further proof.

The next complaint made by Deputy O'Connell is that in some cases the tablets in these pill boxes can be changed by the patients themselves. I think myself that, in relation to patients who are receiving more than one drug and taking more than one drug everyday, I should look into this matter. That matter is worth investigation because of the possibility of there being a crisis in the life of a patient through the patient taking the wrong tablet at the wrong time of the day or taking the wrong number of tablets.

With regard to the boxes being unmarked, the chief pharmacist of the Dublin Health Authority and pharmacists of other health authorities have issued instructions that a label should be placed on the lid of each box, and on each bottle, containing the name of the dispensary and the directions for the use of the tablets. This instruction may not always be complied with. If the instruction is complied with and the box has a label on it quite clearly telling the patient what time of the day to take a prescription and how many pills to take that should obviate some of the difficulties that may arise, as referred to by Deputy O'Connell. Pharmacists may be under severe pressure at times.

Dr. O'Connell

I am sorry to interrupt the Minister, but that would not solve the problem. The changing of the lids is the problem.

Mr. L'Estrange

The lids are changed from one box to another. The patients may take heart tablets to make them sleep at night and the sleeping tablets during the day.

Mr. Childers

I appreciate the danger of that practice, and I will look into it and see what can be done about it. I should say that the whole system will be superseded, if all goes well. Surely the Deputies will agree that if each box is marked with the time of the day at which it should be taken——

Mr. L'Estrange

But they change the lids. On one lid of a box of heart tablets it might be written that the tablets were to be taken three times a day. A similar box might be supplied with other tablets which could be sleeping tablets. This woman of whom I spoke put the wrong lid on the boxes in my own presence. The Minister should issue instructions that if a patient is given two types of drugs he should be given two different coloured boxes, perhaps a white box and a black box, or a white box and a red box. That would get over the whole problem.

Dr. O'Connell

We might abolish the idea of pill boxes and resort to bottles.

Mr. L'Estrange

That would solve the problem immediately.

Mr. Childers

We are getting involved with the combined purchasing scheme. All I can say is that I will look into the question of exchanging the lids on the present pill boxes.

The Dáil adjourned at 10.45 p.m. until 3 p.m. on Wednesday, 11th November, 1970.