Pharmacy staff fail to detect CM harm


‘Pseudo-patient’ researchers found advice that prevented harm was provided by less than a fifth of pharmacists and only 11% of pharmacy assistants

Researchers from the University of Sydney’s School of Pharmacy sent a ‘pseudo patient’ into NSW pharmacies to explore real-life pharmacy practice in relation to complementary medicines (CMs).

One member of the research team enacted the role of a pseudo-patient requesting St John’s Wort for her mother, who happened to be consuming digoxin, verapamil and candesartan for a number of conditions she suffered from.

Pharmacy staff were not made aware of the pseudo-patient’s identity or research purpose.

In the scenario that was enacted, St John’s Wort should not be given to the patient due to evidence suggesting a clinically significant interaction resulting in decreased efficacy of the cardiac drugs digoxin and verapamil.

“Potential harm” in this scenario was considered to be the supply of St John’s Wort.

Of the 110 metropolitan pharmacy visits made, 51 pharmacists (46.4%), 57 pharmacy assistants (51.8%) and 1 naturopath (0.9%) assisted with the pseudo-patient’s request. One pharmacy did not stock the product requested.

Advice that may have resulted in harm to the patient was offered by pharmacists in 11.8% (n = 13) of the encounters, and 20.9% (n = 23) by pharmacy assistants.

Conversely, advice that prevented harm was provided by only 17.3% (n = 19) pharmacists and 10.9% (n = 12) pharmacy assistants.

Less than a third of the pharmacies undertook an “intervention”—which included preventing the purchase of St John’s Wort; referral to other healthcare professionals; and/or offering another product in replacement of St John’s Wort.

History-taking was not attempted by 84 (77%) pharmacy staff, with questions asked ranging from none to maximum three questions.

The researchers found complete history-taking was not undertaken by any pharmacy staff at any point in time during the study.

For example, no pharmacy staff, including pharmacists, enquired about any allergies the patient may have had. One pharmacist asked about other CMs used by the patient.

Products such as Anxiety ease® (n = 1), Lavender pills (n = 2), Vitamin B complex (n = 1), Rescue remedy® (n = 1) and Ashwagandha (n = 2) were alternative products offered by seven pharmacies.

The research team, led by pharmacist Kristenbella Lee, said: “In an ideal situation … and according to standards of practice in pharmacy, pharmacy staff would be expected to refer the patient’s relative to the pharmacist in charge first, to conduct a thorough history taking, then in light of the complexity of the case, refer the patient to a doctor for further investigation.

There is a common perception by consumers that CMs are ‘natural’ and therefore safe, with little regard for the possibility of side effects, interactions and adverse events.

“However, evidence suggests that the chemical constituents and pharmacological effects of some CMs, specifically herbal products, have the potential for harm when taken at certain doses and/or in combination with other medicines,” they said.

Pharmacists have a role to play in ensuring the appropriate and safe use of CMs as part of their scope of practice, the researchers said, adding: “It is … important to ensure good pharmacy practice is implemented, including the provision of thorough history-taking, professional communication and counselling services before the sale of any CMs.”

See the full study in Research in Social and Administrative Pharmacy here

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