Methotrexate death sparks collaborative summit

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The PSA is hosting a summit aimed at uniting doctors and pharmacists on the issue of patient safety

The inter-collaboration summit is set to explore how doctors and pharmacists can work together more effectively to support patient care through the safe use of medicines.

The summit was prompted by a recent Coroner’s report into the death of a Melbourne man following complications of methotrexate toxicity.

In handing down her findings, Coroner Rosemary Carlin said the patient’s unnecessary death resulted from key failings of the pharmacist and prescribing doctor to work collaboratively to effectively resolve a prescribing error.

In particular, the coroner noted that “Doctors and pharmacists should trust and respect each other, whilst retaining their independence”.

“In dismissing her concerns, it appears that [the GP] did not afford [the pharmacist] the respect she deserved.

“In dispensing the methotrexate despite her concerns, it appears that [the pharmacist] afforded [the GP] too much respect, or at least lost sight of her role as an independent safeguard against inappropriate prescribing.”

PSA National President Dr Shane Jackson said the Coroner’s report highlights the need for a more collaborative relationship between pharmacists and doctors that recognises their respective roles and responsibilities while also acknowledging their independence.

“The summit will seek to develop a set of principles to support respectful and collaborative practice between pharmacists and doctors,” Dr Jackson said.

“It is time to work together on key principles that underpin the collaborative relationship between pharmacists and doctors, particularly regarding the safe use of medicines, for the benefit of our patients.

“We have invited other professional bodies to join the summit so together, we can empower pharmacists and doctors to meet their duty of care in regards to patient safety.”

The summit will bring together leaders from key pharmacy, medical and consumer organisations at Pharmacy House in Canberra on 21 August 2018.

The issue of a power imbalance between doctors and pharmacists has sparked a number of discussions at the AJP amongst readers, as well as a piece by experienced pharmacist Jeff Lerner, who argued that there is a real need for assertiveness training for pharmacists.

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  1. Ron Batagol

    There are no easy solutions. The various suggestions and comments in this discussion on AJP daily have been useful, but obviously a coordinated approach to this critically-important issue within the profession is the best way forward. The inter-collaboration summit seems like a good starting point.

  2. Debbie Rigby

    Good leadership by Shane Jackson and PSA.

    Hopefully there will be consensus on our respective roles and the need for collaborative practice in primary care ie between GPs and community pharmacists. How many times have we heard about the 230,000 medication-related hospital admissions?! And the MTX incident with its tragic outcome was avoidable.

    Hospital pharmacists and doctors have been working together all my career, and practice pharmacists have a growing place in primary care. The acceptance is based on mutual trust and respect, and recognition of the shared responsibility we have to ensure quality use of medicines and medication safety.

    It will be a start at organizational level, but we also need take responsibility individually and build those bridges.

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