Professional standards for pharmacy professionals (GPhC)

Managing difficult conversations

Medication error reporting (Datix)

Anaphylaxis management

You are a pharmacist working in a hospital on a respiratory ward.

Mr Daniel Fraser (DOB: 09/09/1973) was admitted with community-acquired pneumonia. Despite a clearly documented penicillin allergy, he was administered amoxicillin during the morning drug round.

He developed facial flushing, an itchy rash and mild lip swelling. He was treated promptly with IV antihistamine and oral steroid, and the reaction has resolved. He is now stable.

Due to ongoing junior doctor industrial action, the consultant has asked you to speak to Mr Fraser and explain what happened, apologise, and outline the next steps.

You have 10 minutes.

You are Mr Daniel Fraser (DAN-yəl FRAY-zər)
DOB: 09/09/1973
Age: 52

Opening statement: “How can I help you?”

Background

• Admitted with pneumonia at 1am after an out-of-hours appointment at the walk-in-centre. 

• Had a chesty cough for 3 days, shortness of breath and tiredness, causing you to be bed-bound, so you thought you should get checked out. 

• Your penicillin allergy has been noted since you were a child in all your medical records. 

• You were given some IV medication this morning but you didn’t know what it was. Shortly after, you were flushed, red and itchy all over and lips were swelling. 

• They gave you another medication and you feel a bit better now.

• You want to know why you got all red and itchy. 
  
  

Emotional tone

Initially calm but concerned. 

Become very angry when you are told you were given a medication you were allergic to. 


Responses

• If the student minimises the issue → refuse to speak. 

• If the student blames others → respond: “So whose fault is it then? Why are they not speaking to me?”

• If no apology is given at the 5-minute mark → say: “So are you actually sorry this happened? You haven’t even said sorry”

• If they don’t explain clearly → say: “I don’t really understand. How did this happen?”

• If they do well → soften and engage.
  
  

Ask these questions if they are not answered by the student: 

• “Who is responsible for this?”

• “Will this happen again?”

• “Is someone going to get in trouble?”

1. General Pharmaceutical Council (2023) New GPhC resources on duty of candour highlight importance of openness when things go wrong. Available at: https://www.pharmacyregulation.org/about-us/news-and-updates/new-gphc-resources-duty-candour-highlight-importance-openness-when-things-go-wrong (Accessed: 3 March 2026).