Saturday Evening in a Kisumu Community Pharmacy

1. Amoxicillin suspension. Lawful to dispense on a prescription from a clinical officer acting within their scope. Two problems need resolution first. The prescription is 24 days old for an acute infection - clinically stale, and the child may have recovered or deteriorated. The dose (5 mL × 3 = 750 mg/day) needs the child's weight: for a 14 kg child that is about 54 mg/kg/day, at the upper end of the 40–90 mg/kg/day range but not implausible. Call the prescriber to confirm weight, indication and whether treatment is still needed; document the call. If the prescriber cannot be reached, do not dispense - refer back.

2. Cefixime without a prescription. Refuse. It is a prescription-only medicine, and dispensing it on request breaches the law and stewardship. Gonorrhoea requires syndromic management with partner notification, and oral cefixime 400 mg single dose is not first-line in most national STI guidelines. Refer the man to a clinic; explain briefly without lecturing.

3. Amitriptyline repeat. Refuse to supply without a prescription - this is not a legal refill. But do not simply turn the patient away: abrupt interruption of a tricyclic causes discontinuation symptoms and relapse. Contact the prescriber, offer to hold the request, and if the prescriber cannot be reached, direct the patient to the prescriber or to a facility the same day.

4. ORS carton. Withdraw the whole carton from sale. Clumping means moisture ingress and the torn foils confirm it; the intact-looking sachets are from the same compromised carton. Do not dispense, do not return to stock, and do not 'use the good ones'.

Records for the three patient encounters: entries in the prescription register for the amoxicillin with the prescriber contact and outcome; a refusal record for the cefixime and for the amitriptyline (date, product, reason, advice given, staff initials) so that a pattern of requests can be reviewed; a note of the prescriber discussions.

ORS handling - physical: move the carton to a clearly labelled quarantine area, physically separated from saleable stock and inaccessible to assistants; do not destroy it unilaterally.

ORS handling - administrative:

1. Open a product quality complaint record: product name, strength, batch number, expiry, quantity affected, storage conditions on receipt, date and time of discovery, photographs of the clumped powder and torn foils.
2. Notify the supplier in writing and request instructions, and notify the regulator through the quality defect reporting channel (the online portal, with the same details and a sample offered).
3. Retain at least one affected sachet and packaging pending a decision, and keep a copy of the complaint on file.
4. Check the stock records for how many sachets of that batch have already been sold or dispensed; if any were, consider whether purchasers need to be contacted.
5. Add an SOP for rejected or suspect stock to the dispensary manual and brief the assistants.

Why this matters: a moisture-damaged ORS is a quality defect, not a customer complaint to be smoothed over. If the batch fails at the laboratory and the pharmacy never reported it, the pharmacy's own record-keeping becomes the finding.

Staffing and supervision. A registered pharmaceutical technologist is on duty alone with two unregistered assistants. Unregistered staff must not dispense, counsel or make supply decisions, so every transaction in that period runs through Mr. Otieno - a queue that invites shortcuts. There is no documented arrangement for the superintendent pharmacist's absence, which means the pharmacy is operating on habit rather than on a written plan.

What should be escalated to the superintendent on Monday:

1. A written absence protocol naming who is in charge when the superintendent is off-site, and the level of registration required.
2. Standing SOPs for: prescription validity and prescriber clarification, refusal of POM requests, quarantine and rejected stock, and quality defect reporting.
3. A refusal register and a policy that assistants are never left to manage the counter alone.
4. A training record showing assistants have been briefed on what they cannot do.
5. A review of whether the pharmacy's opening hours are compatible with the registered staffing it actually has - if not, hours should be reduced rather than coverage improvised.

The judgement for Mr. Otieno himself: he must not let the queue or the cash offer shift the line between lawful and unlawful supply. The correct escalation is written, dated, and specific, so that if the same situation recurs the record shows the risk was raised and not ignored.