Safety warning over unclear scripts


pharmacist holding script, medicine

Unexpected impacts from active ingredient prescribing changes have seen pharmacists ramping up their ‘safety net’ role to prevent dispensing errors

Pharmacists have been stepping up to manage “unintended consequences” arising from active ingredient prescribing measures, which became mandatory from 1 February 2021.

Most computer-generated PBS prescriptions now have to be written by active ingredient, with prescribers still being able to indicate a brand or nominate not to substitute.

Noting that non-conformant scripts could affect a patient’s subsidised access to their medicine, the Government agreed to the Pharmacy Guild’s request to introduce a six-month grace period for dispensing and claiming such prescriptions.

“The Government was not expecting significant changes to pharmacy practice as the change was expected to be mostly with those who initiate the prescription – the prescribers,” said Suzanne Greenwood, Guild Executive Director in a recent statement.

However, she added, “as prescriber software systems have been updated over the past weeks, we are seeing that this is not the case and more than ever pharmacists have been demonstrating the critical role they play as the ’safety-net’ for patients when they have their prescriptions filled.

“What has been obvious over the past several weeks is that while prescribing systems have been updated, there remain flaws in the upgrades of some systems in which some active-ingredient prescriptions are being generated and are not consistent with the new requirements or the recommendations of the Safety Commission.”

Ms Greenwood said pharmacists are being presented with prescriptions in which the intention of the prescriber is unclear and are having to contact prescribers to clarify intentions.

In addition, there are examples of pharmacists having to contact the prescriber to re-write prescriptions so that patients can get the correct medicine.

“These interventions are predicated on pharmacists being able to easily contact the prescriber,” she said.

The presentation of unclear prescriptions when the prescriber cannot be contacted means delays for the patient receiving their medicine, which in itself can be a safety problem.

PDL recently stated that it has received a number of reports and one error related to the changes.

It reminded pharmacists to read prescriptions carefully as prescribing software is likely to present the order of active ingredients alphabetically, which might be different to previous computer-generated or electronic prescriptions.

One noted example is Targin tablets which have been routinely prescribed as oxycodone + naloxone.

Prescribing software programs are now likely to generate Targin as naloxone + oxycodone which could easily lead to confusion or error, said PDL.

There is a report that the strengths of the ingredients may still be presented in the previous format of oxycodone/naloxone.

“Members are advising us of problems they are seeing and in turn we are forwarding this information to the Department of Health and the Safety Commission to urgently address,” said Ms Greenwood.

“I am very proud of the work done by the pharmacy profession which again is stepping up to manage the unintended consequences arising from these Government changes in the interests of their patients.”

PSA national president Chris Freeman told AJP: ​“Every prescription which is not clear, is missing vital information or contains contradictory information is a medicine safety problem and places patients at risk of harm.

“​​Using the information provided to them by prescribers and pharmacists, medical prescribing software companies need to continue to review and resolve glitches and gaps in their programs which are causing these problems.”

He recommended that the Australian Medicines Terminology (AMT) clinical dictionary should be used in all clinical software to ensure consistency around medicines information.

However A/Prof Freeman added that active ingredient prescribing is an important step forward for medicine safety that will ultimately make medicine use safer once these prescribing software issues are all identified and resolved.

“​PSA is working with other peak bodies and the Department of Health to help communicate these issues back to the medical prescribing software companies for resolution.”

What happens next?

The Guild said it is working with the PSA, SHPA, PDL, Pharmacy Board and Medical Software Industry Association to ensure safety issues associated with the initiative’s implementation are expediently resolved.

It has also alerted consumer groups “so that they are aware of the problems and the potential safety risks for their members”.

“Fortunately, the pharmacy profession is doing its job well to protect patients from prescription-related mishaps,” said Ms Greenwood, “but how long can this safety net hold out before something serious happens?” 

“We have let Government know that while we continue to support this initiative, they must take the lead and work with the prescriber groups to iron out these safety-related problems as a matter of urgency.”

Pharmacists are encouraged to keep the Guild informed of any safety-related problems with active ingredient prescribing by sending an image of the prescribed medicine/s (without patient or prescriber details) and which prescribing software (if known) to AIP@guild.org.au

A/Prof Freeman also encouraged pharmacists to forward deidentified copies of any unclear prescriptions to policy@psa.org.au to help them identify specific issues and pass examples of these problems on for review.

What you think

Some AJP readers have shared their thoughts on the recent changes.

“Anyone could have seen this coming. PDL will see a large influx of matters relating to dispensing errors due to this ridiculous active ingredient prescribing rule change. It’s very confusing for both the patient and pharmacist. It should be mandatory to have a brand name in brackets after the active ingredient,” said Matthew.

Breanna commented: “While I appreciate the need for active ingredient prescribing, clearly this has been implemented by people who haven’t worked in community pharmacy for a long time, if ever. Pharmacists already have a large workload; why is it up to us to take on even more work when prescribers haven’t adhered to these new changes? And why should we be copping the abuse and dissatisfaction from patients who don’t see anything wrong with these new scripts, and just want their medicines? Better execution is needed.”

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