An independent responsibility


Gary West presents at APP2019.
Gary West presents at APP2019.

Prescribers often see a query about a script from a pharmacist as a challenge… so how can pharmacists best navigate these difficult situations?

Gary West, professional officer at PDL, presented a Business Bites session at the recent APP conference on the Gold Coast in which he tackled the fraught issue of contacting prescribers with concerns about a script.

He cited a number of recent examples of inappropriate dispensing, including two cases where patients died after being given medicines inappropriate for them, including methotrexate and opioids.

In one case, the coroner specifically stated that “pharmacists bear responsibility for patient safety as other health professionals do”.

“The regulators are involved in these cases, and it demonstrates that they do believe supply of excessive quantities… or more frequent supply than normal, even with prescriber approval, does not absolve us of responsibility,” Mr West warned delegates.

“Regulators have taken disciplinary action against pharmacists, and I suspect prescribers… in situations such as this, even when the pharmacist has rung the doctor and the doctor says ‘I’m comfortable prescribing this drug’.

“The regulators believe we have an independent responsibility.”

Pharmacists also need to start thinking proactively ahead of the rollout of real time monitoring, which is likely to pick up instances where pharmacists are concerned about scripts, across the country, he added.

If a disagreement exists regarding whether a script is safe and appropriate, professional judgement must be exercised by the pharmacist,” he said.

“This professional judgement may include a decision not to supply until the pharmacist is satisfied that the risk or concern has been addressed appropriately, even if this means a delay in supply.

“Generally speaking, you won’t be penalised if you’re taking an appropriate stand in the best interest of the patient.

“At all times the dispensing of a prescription or any other action taken by the pharmacist, must be consistent with the safety of the patient. If the pharmacist decides not to dispense the prescribed medicine, the patient must be informed about the reasons for the decision and the alternative options available to the patient regarding their medication needs. “

Patients should also be provided with some sort of documentation, such as a CMI with relevant sections highlighted, explaining that the decision not to dispense was based on clinical evidence.

Pharmacists should also document for their own records that the script was not filled and why, and that information was provided to the patient.

“Don’t rely on your memory,” Mr West said, telling delegates that they should document the interaction immediately.

Mr West said that if pharmacists have any doubts “whatsoever” about a script, they should contact the prescriber, and not rely on what the patient tells them.

“Complacency is not an option. Once you know, you know. You can’t un-know it. You have to be engaged and involved.”

Mr West told the delegates that there are often common factors or themes seen in professionally challenging situations such as those he described: the medicines involved are typically those with known potential for misuse, dependence or diversion, and patients may use emotional manipulation to convince the pharmacist to dispense the medicine.

The patient may be collecting medicines via staged supply; there may be frequent excuses for early supply; and the GP may be overwhelmed or unconcerned, or in the case of one example Mr West cited, frequent turnover of GPs in a practice or the use of several GPs may be a factor.

The patient may be subject to factors which impede or prevent referral to specialist or in-patient treatment, and there may be the potential for an adverse health impact if supply is suddenly ceased, such as when a patient may have developed a dependency on a medicine.

Mr West outlined a number of options which pharmacists can consider in such situations:

  • Confirm indication
  • Review patient history
  • Check urgency and duration
  • Confirm contraindication or precaution with patient
  • Ascertain if prescriber is informed
  • Review references
  • Use other resources, such as evidence-based websites, drug information centres, Therapeutic Guidelines and perhaps State Drugs and Poisons Regulations
  • Discuss the concerns with the patient
  • Contact the prescriber before supplying
  • Ask the prescriber for references
  • Ensure the discussion is collegial
  • Delay or decline supply if the concern is significant
  • Seek advice from another practitioner
  • Document conversations and actions
  • As a last resort, notate the prescription if the pharmacist is giving it back to the patient – for example, if the patient is behaving in a threatening manner – that the script was not dispensed. This way, if the patient takes the script to another pharmacy, the next pharmacist to receive it will be alerted to your concerns.

However, contacting prescribers to discuss concerns can be challenging for a lot of pharmacists, Mr West said.

Young pharmacists, locums and those who do not have a lot of support may find it particularly difficult to be put in this situation.

“Good communication is paramount,” Mr West said, adding that PDL does see complaints made against pharmacists where it’s clear that communication was poor and there were misunderstandings.

Pharmacists should maintain a professional approach in all contact with prescribers, even in situations where the prescriber might be acting in an unreasonable manner.

“I talk to pharmacists quite regularly, unfortunately, who’ve had difficult discussions with doctors – doctors feel very challenged, sometimes, by pharmacists contacting them… and they need to understand that you’re doing it for the wellbeing of the patient.

“Don’t escalate your emotions or match their behaviour, particularly if they’re rude or overbearing. Just try to de-escalate it, document the discussion, and attempt to do your best.”

Being prepared is also important. Mr West said that before providing advice or information, pharmacists should be sure they have sufficient information to do so – for example, was the therapy initiated by a hospital or specialist, and is there some documentation the prescriber could provide to reassure them, or that the pharmacist could keep on file for future reference?

Pharmacists should ensure that all the relevant patient and drug information has been considered before engaging with the prescriber, to ensure that the communication is efficient and clinical.

“Establish if there’s a more appropriate time or a means to communicate,” Mr West advised. “Doctors are very time-poor. Trying to engage with them, particularly about a really serious issue, requires some time and explanation.

“If it’s not vital it’s supplied immediately, ascertain if there’s a better time to talk to the prescriber, explain the serious nature of the situation, send an email and say, ‘I’ve left a message with the receptionist, this is a very important case that we need to discuss, I’m prepared to be contacted at any time, this is my mobile number’ or something like that.

“Make every effort and document it if you can.”

Mr West reiterated that this does not mean pharmacists should supply now and discuss the script with the prescriber later.

“Even if you tell them, ‘don’t take it until they take your call,’ that’s not appropriate. People unfortunately don’t always listen, they don’t always understand or make assumptions.”

When they speak to the prescriber, pharmacists should state that their concern is for the patient’s wellbeing, Mr West said.

“Try to seek language that’s not a criticism of the prescriber. Sometimes, unfortunately, prescribers will feel it’s a challenge.

“The best you can do is provide them with all the documentary evidence, and if you choose not to supply, you explain that that’s your choice, and that you have an independent responsibility to the patient.

“Bring it back to patient health. It’s not a challenge.

“We have situations where prescribers threaten pharmacists – that they’ll be reported to the Board. They’re typically [just] threats.”

He said he had seen very few cases where doctors actually referred a pharmacist to AHPRA under these circumstances.

“It’s again, just an insight into their discomfort with the challenge from the pharmacist,” he said.

“I talk to a lot of younger pharmacists, less experienced pharmacists, often working hard, trying to do the right thing,” he said, telling delegates that if they have any opportunities to provide some mentoring, as a more experienced pharmacist, this would help.

“Any support, making your younger, less experienced pharmacists aware that if they have difficult situations they can contact a colleague, contact a friend, maybe the employer, even if the employer’s not necessarily in the pharmacy – somebody they can rely on.”

Being able to talk to other pharmacists who have faced similar situations could make all the difference to a less experienced pharmacist, he said… as is discussing what solutions the mentor used, and what they feel they could have done better.

PDL members can call 1300 854 838 Australia-wide for confidential advice and support.

Readers who are distressed can contact the Pharmacists’ Support Service on 1300 244 910.

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