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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  1. Ex-Pharmacist

    Anyone surprised?

  2. actnowpharmacists

    Absolutely not surprised. Pharmacy assistants are not the same as PHARMACISTS who would’ve done a five years degree plus an year of internship before working as a pharmacist. Yes you can teach them asking few questions before making a sale but they just cannot assume the role of a Pharmacist and to expect them to have the same approach is just ridiculous. If you ask me pharmacy assistants shouldn’t be allowed to dispense or use dispensary software either because they won’t be able to identify anything from the previously dispensed medications. But that’s just an industry accepted way for Pharmacy owners to reduce their costs by having multiple pharmacy assistants dispensing and just one pharmacist “checking” the dispensed medications.

    Researchers are crying out loud for Pharmacists not taking “complete life history” before selling something which is freely available on Woolworth. They should’ve started their research with the dispensary. I mean how many times you’ve seen a Pharmacist coming out of the dispensary to take history before dispensing a prescription medication. We are talking prescription medications here. Patients are not willing to wait 10 minutes to have their prescription medication done correctly let alone allow you to ask intrusive questions about st john’s wort. I am not saying don’t do the right thing and hand them out like lollies but at the same time I’d say researchers, PSA, Guild and the pharmacy owners are way out of touch with reality. Don’t take my word for it. As an employee pharmacist try spending 15 minutes taking a thorough history before making every St john’s wort (not to mention prescriptions as well) and then answer owner’s question “What the hell are you doing?” Patients absolutely deserve the best service possible but does Medicare, PSA, Guild, and Owners upto the task.

    • Arvin Mangahas

      On top of that the biggest issue is remuneration for pharmacists. Every single primary care consultation should be eligible to claim under an MBS item. This is ridiculous that you expect pharmacists to provide so much care to every single patient that walks in for free when their time is so constrained already with other workloads and responsibilities. This is reality and things need to change within the profession to enable pharmacists to be appropriately remunerated. No doubt we already know this that pharmacists are more than capable to handle these sort of CM queries but the issue is remuneration and time constraints, workload on and on.

      • TALL POPPY

        Correct. GPs can get $300k++ per annum and now pharmacists are expected to be pseudo-GPs without any extra remuneration for a fraction of that. You are so naive or just blind to accept extra workloads for no extra. It’s not right.
        There is no income progression in pharmacy whatsoever for employees. And, in fact, pharmacists are earning LESS now than 10-20 years ago! How’s that…simple…when was the last time you were offered a pay rise in line with inflation? Pay rises should occur yearly. If they did, you would be on minimum $55/hr.

        It is high time that the ownership rules were relaxed & limits imposed on individuals so that it is fair for your average pharmacist to open up a store. High time. It’s not going to happen unless the Govt is lobbied appropriately.
        Good luck.

        • Jarrod McMaugh

          “It is high time that the ownership rules were relaxed & limits imposed on individuals so that it is fair for your average pharmacist to open up a store”

          the goal of easier ownership I agree with. This approach you’ve mentioned here wouldn’t do that (well, limits would), but opening up ownership rules would instantly obliterate any chances young pharmacists have of ever being an owner

          • TALL POPPY

            I should have said location rules – not ownership rules. I was generalising. As in I believe that only a pharmacist should own a pharmacy. As you agreed, strict limits need to be imposed.
            Just an example suggestion: licenses for new sites should be for 100% ownership (head lease and all paperwork should be under the one owner and audited to avoid proxies etc) and are to be given to those who have no interests (financial or otherwise) in any other pharmacies. This is one way young (or experienced) pharmacists could enter on their own. And be the owner 100%. Market forces will determine if they fail or succeed.

            Would love to hear other suggestions of benefit.

          • Jarrod McMaugh

            I wouldn’t want to be 100%

            there is a benefit in having a partner who has a smaller stake, who is a major stakeholder in another pharmacy

        • Dr Evan Ackermann

          What would happen if the pharmacist got the fee for service (prescriptions etc) not the pharmacy?

          • TALL POPPY

            An interesting proposition. A base retainer + fee for service could work with the owner taking an appropriate percentage. You could sit down and calculate this and would be an incentive to grow Rx trade + give a sense of ‘ownership’. However, many pharmacies have high rental costs compounded by annual 3-4%+ increases which need to be covered and owners are unlikely to want to give any profit up.

            Interestingly, I have found that many well-run pharmacies could afford to pay their pharmacists an extra $5/hr if they wanted to whilst maintaining a healthy net.
            There are many professional pharmacists out there doing the right thing but they are simply not getting fair remuneration. No where near.

            The problem with the industry is that there are many pharmacists wanting to get into 100% or majority ownership to do their own thing. And the current setup simply doesnt allow for that: the best pharmacies/locations are almost always taken up before they reach the open market.
            Brokers have lists of their best clients (usually owners of groups) and will present such opportunities to them first and foremost.
            The crumbs on the table are generally what is left on the market & what you see advertised. The other option is to be a puppet owner – a minority partner that does 100% of the work often for a fraction of the profit. And no real power as to the direction of the business. This is again not what ownership should be about.

            Change is needed – the current situation is far from good.

          • actnowpharmacists

            I don’t see it happening in my lifetime.

            Fee for service definitely going to benefit a larger set of pharmacists than smaller rich pharmacy owners who don’t necessarily put their registration on stake providing day to day service in the pharmacy. The chances of making an error goes up when the workload increases and while no owner will admit that their employee pharmacist is under the pump, there are no set limit/guidelines as to how many scripts/activities a pharmacist can undertake with the acceptable level of attention to details. The more volume the better, from owners perspective. That’s why many pharmacist feel overworked and not satisfied with the job because no matter how good you are at your job, at the end of the day “Price” trumps everything. The owner basically wants an employee to act like an “Owner” but the reality is you have little to no chances of becoming an owner of the pharmacy. There are certain trends when it comes to the pharmacy ownership. Its either both you and your partner are pharmacy owners, OR You are a child of a parent who owned the pharmacy and that’s how you got your pharmacy OR obviously as rightly put by tall poppy, you become a puppet owner and wage price wars. Your average pharmacy wont’ be able to make ends meet if they don’t sell Chlorophyll liquid, nappies, toothbrushes and what not. As a GP would anyone be interested to sell Milk and Bread to make ends meet? We all have to admit GP’s job is not easy either. They go through a lot as well but they are being paid way more disproportionately compared to the other health professionals. If quality of medical care you get is directly proportional to remuneration then how come pharmacist’s salary seems to be going down down. Australia is so far behind compared to the rest of the world in terms of innovation (in pharmacy), I am not sure if they’ll ever catch up. They couldn’t go past vote scoring, lip servicing and a dollar co payment discount.

            Ownership/location rules have failed miserably at preventing big conglomerates to own pharmacies in Australia. They were supposed to keep the pharmacies in the hands of someone who is locally involve with people at the community level. Instead we have got Giants both at retail and wholesale level deciding the fate of smaller / locally owned pharmacies. What you’ll do if your wholesaler doesn’t give you bulk discount. The ownership/location rules needs to be tightened as i find single owner owning six pharmacies and planning to buy more a bit too much to accept. I had a teacher at a university who owned seven pharmacies in different states. This is nothing compared to someone having an interest in 300+ pharmacies.

            Not every pharmacist would want to go through the stress of being an owner but i am sure they’ll all settle for a decent remuneration reflecting the kind of a job they are being asked to do and a little appreciation that they are indeed integral part of a health care system.

        • Paul Sapardanis

          Ownership of pharmacy is already relaxed. You just need to do it with a marketing group heading up the chain. Lets stop kidding ourselves that this is not the case

  3. Sietel Singh Gill

    There are studies that move the needle and effect change and then there are studies like this. The relevance and relative likelihood of a St John’s Wort interaction posing a sizeable risk to patients across Australia is, well, hardly significant. Stacked up against numerous studies involving pseudo patients potentially assessing harm minimisarion, this study is academic, which is to say, the stakes are low. There’s a pseudo-Beckettian play to be set in the university of Sydney pharmacy research department. It’s lineball whether this comment of mine or the study is less necessary to the world.

    • Dr Evan Ackermann

      perhaps you need to update on

      TGA advice – St John’s Wort: Important interactions between St John’s Wort (Hypericum perforatum) preparations and prescription medicines

      and more recently –

      Co-administration of St John’s wort and hormonal contraceptives: a systematic review. Contraception. 2016;94(6):668-677. doi: 10.1016/j.contraception.2016.07.010
      with subsequent guideline clinical advice on SJW and contraception.

      • Sietel Singh Gill

        Dr Ackerman, how many confirmed incidences of this interaction were reported in 2019?

        • Dr Evan Ackermann

          I would imagine it very low. Reported adverse reactions are known to be low, and those for CM even lower.
          However reported adverse events is not the same as risk is it.
          How do you inform women on the OCP if they are to purchase/take SJW – or even those who request emergency contraception?

          • Jarrod McMaugh

            Specific advice about the use of medicines should not be discussed on this platform

          • Dr Evan Ackermann

            There is no specific advice to anyone in this discussion

          • Jarrod McMaugh

            A response to your question may constitute specific advice, or may be taken as such by readers.

            Ensuring that specific advice isn’t included in any response

  4. Matthew Dawson

    While I was still practicing, at minimum I would ask the following questions.

    Is this medication for you?
    Who has recommended you buy this medication (or CM)?
    Do you have any allergies?
    What other medications do you take?

    St John’s Wort is known to have interactions and Digoxin should always be a trigger for Pharmacists to check on the potential interactions with CM’s given it’s narrow therapeutic range.

    We used to run training sessions for our Pharmacy Assistants on all S2 and S3 products plus the most common CM’s. If in doubt they should always ask the Pharmacist to help them.

  5. Bruce ANNABEL

    The study points yet again to the underutilisation and misapplication of highly trained/skilled pharmacists and the use of assistants engaging with ‘customers’. Isn’t it time the fundamental professional pharmacy model and business was changed that I have lobbying and writing about for 20 years?

  6. PeterC

    Apart from everything else, this is a scheduling anomaly. Nothing with a known high ADI potential should remain unscheduled.

  7. George Papadopoulos

    Simple solution: pharmacists should put these products amongst S3s

  8. Andaroo

    Start funding pharmacists time directly and i guarantee a better patient history would be taken and more questions asked…

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