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‘You are not obliged to dispense every single prescription’: Experts remind pharmacists to use independent judgement and not give into peer pressure

Community pharmacists have been reminded of the importance of exercising their own clinical, independent judgement – both to ensure patient safety and to protect themselves from the regulators.

PDL takes calls “all the time” on the autonomy of pharmacists being challenged, PDL Professional Officer Gary West said in a recent AJP webinar on pharmacist and proprietor responsibilities.

“Often the autonomy is being challenged by a patient, as you’d probably expect. But we do have situations where it might be prescribers with expectations and demands on pharmacists to supply what’s being prescribed irrespective of the pharmacist’s concerns,” he said.

“Sometimes it can even be colleagues or employers. Obviously when it comes to things like the patients, you’ve got to be thinking – what is their agenda? What is their reasoning?

“The classic scenarios are typically the over-the-counter products such as Rikodeine mixtures or the Restavit products that might be used in a less-than-ideal manner, and the comments are, ‘well, I’ve had it from your pharmacy before, your colleague here or the other pharmacist gave it to me’, or ‘I got it from another pharmacy down the road, you must give it to me’. Those sort of challenges do occur.”

Mr West emphasised the importance of documentation, particularly when it comes to a prescriber interaction.

Proprietor responsibilities: your questions answered. See our extended Q&As on proprietor responsibilities here

“We get cases where there is a complaint made often by the patient, but sometimes by the doctor, and the pharmacist doesn’t have any details, no record of it and if it’s months down the track, it’s very hard to go back to your memory. So documentation is key,” he said.

“From our experience at PDL, situations where pharmacists are concerned about a dose and contacting a doctor – [you should be] documenting not only what your concerns were and the advice or recommendation from the prescriber, but if you choose to decline to supply clear documentation, why you chose to decline and what alternatives were given to both the client and also your response to the doctor.

“You are not obliged to dispense every single prescription. If you think there is a risk to the patient’s health and wellbeing, you can choose to defer it or decline it.

“There are lots of situations where autonomy is challenged—you’ve got to think about motivations, you’ve got to think about your obligations, and you’ve got to know the legislation.”

We are responsible for the clinical decisions we make. These should be made without peer pressure or inappropriate external advice.

Chandrika Darroch, a solicitor from Meridian Lawyers focusing on insurance and health law, agreed with Mr West on the importance of documentation.

“Even if you have a telephone conversation with somebody, you should in your pharmacy have a procedure or policy that requires that conversation be documented somewhere,” she said.

“For example if you’ve had a conversation with a prescriber about a prescription that you thought was a little bit strange or you queried and you made some independent inquiries and were then satisfied it was safe – well, document that.”

Ms Darroch said in the webinar that she also quite often sees “perhaps a reliance too much on the actual prescriber who is making the order”.

“I think that sometimes gives a pharmacist some comfort that they really shouldn’t have for the time. So if you receive a prescription or an order that you’re not really clear on or sure about, you need to ask the prescriber, you need to clarify the order before you go and supply that medication,” said Ms Darroch.

“That’s something that I do see quite often is there’s far too much reliance on what the prescriber has ordered as opposed to the pharmacist exercising their own clinical, independent judgement to make sure that that is actually safe and appropriate to be supplied to that patient.

“We do of course see incidences where complaints are made against pharmacists who have tried to exercise their independent, clinical judgement, have pushed back and said to the patient: ‘No, I’m sorry that’s not safe’ or ‘I can’t do that for you’.

“Of course that upsets patients, you just have to try and explain the position you’re in and the reasons for why you’re refusing supply. But please don’t get into that situation where you just do things because it’s going to make life easier ultimately, because it actually won’t.”

Missed the webinar? Watch the full recording for ‘Avoiding the pitfalls – a practical discussion of pharmacist & proprietor responsibilities’ here

PDL Professional Officer Georgina Woods urged pharmacists to remember that they are independently registered practitioners.

“We are responsible for the clinical decisions we make. These should be made without peer pressure or inappropriate external advice.

“Obviously we can use external advice, we do that every day. We chat to our patients, we might seek further advice from the prescriber, we use resources and legislation and certainly other tools like My Health Record and real time prescription monitoring.

“But it’s really important to be mindful that these are tools and ultimately the clinical decisions we make are as an autonomous practitioner.

“So we need to be able to justify those actions, especially if we’re scrutinised.”

Top tips from the webinar include:

  • Know the legislation in your state or territory.
    “Not knowing the legislation is not a reasonable excuse,” said Ms Woods.
  • Proprietors, managers and pharmacists in charge need to be aware of their greater level of responsibility.
    “The expectation of regulators is there is a very firm connection between proprietors and their managers and this has certainly been highlighted recently with the large number of regulatory activity moments we’ve seen,” said Ms Woods. “Proprietors can take responsibility for certain areas even if they’re not actually present at the time.”
  • Have good policies and procedures in place.
    “There’s expectations that owners have good policies and procedures in place and that the staff, the pharmacists are complying with those policies and procedures and reporting back to the owners,” said Mr West.
  • Document all incidents and important interactions/conversations.
    “The regulators view the issue that if it’s not written down or recorded, it didn’t happen,” said Ms Darroch.
  • Reflect on incidents and make a clear plan to avoid repetition.
    “Regulators not only ask what happened … but what steps have been taken prevent it happening again. You really should be reflecting on incidents after they happen and taking steps to change it and documenting that and having staff meetings if necessary,” said Mr West.
  • Report all incidents to your indemnity insurer.

PDL is available on 1300 854 838 to speak with a Professional Officer 24/7, Australia-wide.

See our extended Q&As on proprietor responsibilities here

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  1. patrick Mahony

    There is a distinct difference between the income of a pharmacist dispensing a prescription and a GP writing a prescription.
    A pharmacist’s income in Australia is dependent on dispensing.
    In Canada in the late 1990’s I attended on behalf of the Pharmacy Board of NSW, a working meeting on real time dispensing and claiming.
    One of the options available in Canada was that a pharmacist could decline to dispense a prescription for a number of reasons, from inappropriate, incorrect information, contra-indication to name a few.
    The pharmacist/pharmacy who/which declined to dispense, recorded all information and explained this to the “patient”.
    The pharmacist/pharmacy was paid DOUBLE the dispensing fee for this service. (NB the Canadian dispensing fee at that time was a single constant figure, irrespective of the price of the medication).
    According to the Canadian authorities at that time, the cost benefit to the Government far out-weighed the cost of the service. From wasted medication, hospitalisation and other adverse outcomes.

  2. Michael Khoo

    The biggest problem is the lack of education provided to prescribers about faxed and emailed prescriptions, and the limitations thereof. I waste so much time verifying restricted drugs that are faxed at all hours and not on safescript,

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