And do we need another death before we as a profession show real action, asks leading pharmacist
Prescribers and pharmacists need to better cooperate and communicate for the sake of patient safety, argues Dr Mark Naunton, Associate Professor and Head of Pharmacy at the University of Canberra.
In a recent editorial for the Journal of Pharmacy Practice and Research, he writes about the “profound impact” the story of Melissa Sheldrick had on him, after hearing it at a conference in Canada.
Ms Sheldrick’s son Andrew died after he received baclofen instead of tryptophan.
“On my return to Australia, I was saddened to read the coroner’s report on yet another patient death due to a medication,” he says, referring to a recent Victorian case.
Ian Gilbert died when dispensed methotrexate at a dose of 2.5mg twice daily.
The coroner ruled that Mr Gilbert’s death was “needless and entirely preventable”.
Dr Naunton notes that the pharmacist contacted the prescriber about the inappropriate dose, but was informed that the dose prescribed was correct.
“The prescriber was described by the pharmacist in the coroner’s findings as ‘firm, confident and resolute’.
“However, the pharmacist was not reassured by the prescriber about the (inappropriate) methotrexate dose; the pharmacist even changed the instructions on the medication label (and then changed it back).
“Why did the pharmacist dispense this lethal dose of methotrexate?” he asks.
“Did the pharmacist in this case feel disempowered?
“In the coroner’s findings regarding the death of Ian Gilbert, it was noted by the pharmacist that she believed there was a power imbalance between the pharmacist and the doctor.
“In this case, the pharmacist was clearly knowledgeable and identified an error; perhaps if the GP had been more receptive and the pharmacist more assertive, then the outcome may have been different.
“Perhaps we need to reconsider pharmacists’ competence to practice and consider more overtly their competence to practice persuasively?”
Dr Naunton is not the only person to suggest this.
Just recently, experienced pharmacist Jeff Lerner wrote in the AJP arguing that the methotrexate case “indicates a real need for universities to provide assertiveness training during pharmacy courses”.
“Do we need another death before we as a profession show real action, rather than just publishing another error and hoping we learn our lesson?” asks Dr Naunton.
“I hope not. I also hope our medical colleagues will work with our profession to ensure doctor–pharmacist interactions are conducive to benefiting the patient.
“The time to change the way we communicate is now. Ian was a father: he didn’t have to die.
“Andrew was 8 years old: he didn’t have to die.”
Read Dr Naunton’s full editorial here.