Despite pressure from prescribers or patients, pharmacists should stand firm in ensuring any script they dispense is appropriate and safe, say experienced pharmacists

Early last month Fairfax media reported on the inquest into the 2015 death of 77-year-old Ian Gilbert, who was prescribed a twice daily 2.5mg dose of methotrexate to treat a flareup of psoriasis on his back and legs.

The inquest heard that when the pharmacist was presented with the script, she became worried that the dose could be lethal, and telephoned the doctor with “extreme concerns”.

In response, the prescriber told the pharmacist that he did not wish the dose to be changed, and despite her concerns the pharmacist proceeded to dispense the medicine.

Mr Gilbert died two weeks later from complications of methotrexate toxicity.

Scenarios involving a dispute between the pharmacist and prescriber aren’t uncommon.

In a poll run by the AJP, 30% of respondents (n=493) said they have had to push back on a script “several times”.

Only 5% of respondents said “this has never happened to me”.

About 63% said they have been in a situation where they had concerns about a script, contacted the prescriber and refused to dispense the medication.

However a significant amount – 24% of respondents – stated they have had concerns about a script and contacted the prescriber, but felt pressured and dispensed the medication anyway.

A fifth of respondents (20%) have been in a situation where they never got in touch with the prescriber but refused to dispense the medication.

And 5% said they have had concerns about a script, didn’t contact the prescriber and dispensed anyway.

‘Right to refuse supply’

Pharmacy indemnity provider PDL says all pharmacists have a duty of care to ensure that any script they dispense is appropriate and safe.

“If a prescription raises concerns, the prescriber must be contacted and these concerns raised,” says PDL.

“Even after insistence from the prescriber that a script not be altered, a pharmacist has the right to refuse supply after informing the prescriber of their concerns and reasons.

“The role of a pharmacist is not to be a mere rubber stamp for all prescriptions received,” says PDL.

“When the dispensing of a prescription is denied by a pharmacist, the consumer should be referred back to the prescriber after being tactfully informed there are concerns about the prescription.”

‘Always ask if concerned’

Experienced pharmacists agree that in the face of pressure, pharmacists need to stand their ground and refuse supply if presented with a concerning script.

“In my career, I’ve refused to supply perhaps 100 times – that’s in about 20 years,” says Victorian pharmacist and proprietor Jarrod McMaugh.

“A lot of the time it has been for opioid replacement therapy initiation doses that are unsafe…. and in those cases it’s usually an issue of starting at a safe dose despite insistence from prescriber to start higher (so not a refusal to supply, but a refusal to supply at the demanded dose).”

“My general advice is to always ask if concerned,” says Mr McMaugh.

“If your concerns aren’t addressed by the prescriber, then advise that you aren’t comfortable with dispensing the medication. Annotate the prescription and return it to the patient.

“A pharmacist should always ensure that the next pharmacist is able to see that a medication has been refused, so they can determine if the prescription is appropriate.

“A pharmacist should also never dispense a prescription just because ‘someone else will eventually dispense it anyway’ – this is not a good reason to dispense anything.”

Dr Gregory Kossena (PhD), managing partner of Priceline Pharmacy Cowes in Victoria, says he has also experienced many scenarios where refusal to dispense a prescription was the appropriate pathway.

“The majority of these end in cancellation of the prescription and it being changed to something more appropriate or the patient being notified to return to the prescriber for further assessment,” says Dr Kossena.

“It really is the job of the pharmacist to use their experience to step into such situations. If a prescription is not in line with recommended or ‘common’ practice, it should be expected that the pharmacist questions it.”

The major problem often seen is reluctance or hesitation of the pharmacist to act based on ‘experience’, due to not wanting to question a ‘senior’ medical practitioner, he says.

“I have seen many examples where a younger pharmacist is spoken down to (often not able to get a word in) by medical practitioners over the phone.

“I have even had a case of a younger female pharmacist employee being ‘intimidated’ by an older male medical practitioner demanding things that most would consider unreasonable, simply because they are the ‘doctor’.”

“This is definitely not something new. But it is fair to say that while such arrogance exists in the medical field, we are also blessed with many wonderful medical practitioners who are more than open to the advice of the pharmacist, and in fact welcome it as a safety shield for their own practice.

“It is vital to involve the patient in such situations, as many unnecessary questions can be answered by obtaining more of a background before making the call to a prescriber.

“It is also important not to speak in an accusatory manner, as this is only going to cause unnecessary barriers and be of no help to either the patient or yourself.”

Failing a safe and acceptable outcome, such as in the example of the methotrexate, Dr Kossena says it is pharmacists’ duty to inform the patient of the safety issue.

“This is vital – they should not leave the pharmacy being unclear as to why we refused to dispense, as it is likely they may go elsewhere and get it dispensed without understanding the reasons.

“If a safer outcome has not been achieved and the medication is vital, I would specifically tell the patient the recommended dose of the medication then tell them what the doctor has prescribed. I would make a very clear disclaimer that if it were ‘myself’, that I would either take the recommended dose or get a second medical opinion.”