‘Script owing’ culture leads to diverted oxycodone

A pharmacist’s “perceived lack of security” in his employment influenced his failure to adequately supervise a technician

The South Australian pharmacist has been reprimanded and conditions imposed on his registration after he faced a tribunal over professional misconduct.

The complaint against him concerned the steps to dispense oxycodone, failing to secure oxycodone, the lack of timely record keeping and the lack of supervision regarding dispensing the drug.

Among the pharmacy’s clients were the residents of an aged care facility, including one Ms H, who was routinely prescribed oxycodone among other drugs, the complaint alleged.

Between October 2014 and May 2015, the pharmacist – in accordance with monthly prescriptions – wholly dispensed the oxycodone by supplying it from the pharmacy safe to a pharmacy technician, Ms M, for packing in Webster packs.

He was to ensure a record was made in the pharmacy’s system, and ultimately, dispensed the oxycodone and other prescription medicines to the customer.

“Over the relevant period, in the absence of prescriptions issued by a treating medical practitioner, the respondent on multiple occasions over the relevant period took steps to dispense such medication (but such medication was not ultimately dispensed by him from the pharmacy) by: providing oxycodone from the pharmacy safe to Ms M on the basis it was to be packed into Webster packs; ensuring that a record was made in the pharmacy prescription system; [and] ultimately entering such dispensing in the drug of dependence register of the pharmacy,” the complaint read.

However the complaint alleged that on those occasions he failed to limit his provision of oxycodone to Ms M for packing by reference to the patient’s prescribing history and other information.

Once the amount of oxycodone provided to Ms M had substantially exceeded the patient’s monthly requirements, the respondent then failed to refuse to provide oxycodone to her for packing without a prescription, the Tribunal noted.

He also failed to ensure that Ms M packed the oxycodone by making adequate checks of her activities; failed to take adequate steps to ensure the prescribing practitioner had been spoken to and did not refuse to provide Ms M with further oxycodone notwithstanding that failure.

He further failed to ensure that, once packed into Webster packs, the oxycodone was returned to the pharmacy safe; and having provided the oxycodone to Ms M, did not always make timely entries in the drug of dependence register such that there was an accurate and consolidated record of stock at all times.

The Tribunal noted that the dispensing conduct in question was “serious in that it occurred without a prescription on multiple occasions each month, where the cumulative effect of the dispensing without a prescription should have caused inquiry”.

“Further, it occurred without checking with the prescribing doctor in advance, or following up immediately thereafter with the doctor in relation to the issue of prescriptions. As a result it permitted the actual diversion of oxycodone within the pharmacy.

“The relevant dispensing conduct involved failures across a range of pharmacy practice including not checking prescribing history and other information; taking steps to dispense without a prescription; failing to take precautions as regards the control of drugs of dependence; failure to take responsibility as a pharmacist to supervise a technician and to follow-up on securing drugs and failure to make timely entries in the drug of dependence register.

“As a result of the latter there was a loss of accounting control of the quantity of oxycodone in the pharmacy that gave rise to the potential inability to manage stocks.”

The complaint alleged that the pharmacist’s behaviour was negligent, not dishonest or disgraceful.

The respondent contended that when he started work at the pharmacy in October 2014, he was not particularly experienced, having only been first registered in 2010.

“He found himself in a pharmacy which by his observations had a certain practice or culture,” the Tribunal noted.

“Due to his perceived lack of security in his employment he failed to take responsibility for the situation.”

A pharmacist who worked with the respondent in the same pharmacy made a statement to AHPRA that “the pharmacy had the practice of dispensing Schedule 8 medicines on an owing basis”.

“It was something that happened at the pharmacy of which the respondent was aware.

“The dispensing on a script owing basis was confined to the packing of Webster packs. At the time the respondent considered that if the medication remained in the pharmacy it was okay [as] it was Webster packs were not being secured in the safe after packing.

“An audit revealed that large amounts of oxycodone had gone missing.”

Following the notification the respondent lost his job and has struggled to obtain full-time employment since.

He has undertaken a significant amount of relevant education since, at his own initiative and cost.

He sought to avoid a reprimand, particularly given he was considering registering in Singapore – not possible following a reprimand.

The Tribunal accepted that the pharmacist has gained “clear insight” into his behaviour and the dispensing requirements of S8 drugs, but issued a reprimand and imposed certain conditions on the pharmacist’s registration.

These included that he may only practise only in place(s) of practice approved by the Board/AHPRA (indicating one pharmacy); that he must be directly supervised by a nominated pharmacist when handling any S8s; must not supervise another pharmacist; and must be mentored by another registered pharmacist in relation to certain topics, such as managing personal work priorities and professional development.

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  1. Jarrod McMaugh

    I have had nursing homes where the doctor advised the facility to find a new pharmacy when we refused to supply schedule 8 as “owing” based on charts.

    As recently as October, I had a patient who was living in a facility who was convinced to change pharmacies because we refused to supply narcotics without a script.

  2. Apotheke

    I have worked in a Pharmacy that had an extensive nursing home business and owing scripts were a major problem, particularly owing scripts for S8 drugs. Nursing home patients being given S8s were often undergoing palliative care.When they died the Pharmacy had only a very short window of time to obtain the necessary prescriptions from the doctor(s) concerned and have them put through the dispensing system in order to get paid under the PBS. I believe that a patients Pension Concession card, Veterans card and Medicare card are cancelled by the Human Services very quickly after they have been notified of a death. In my experience at that Pharmacy the bulk of the GPs did not care that the Pharmacy was (a) Breaking the law by supplying S8 & S4 medications without a valid prescription (b) They were in no hurry to provide prescriptions for either S8s or S4s upon a patient’s death The Pharmacy was literally forced to write of the supply of these medications as a bad debt. Maybe this is an issue the PSA & Guild can take up with the RACGPs for them to run an educational component on legislation governing prescription and supply of S4s & S8s in their training program for Vocational registration of GPs.

    • Steven Ung

      Alternatively, if every pharmacist practised the way they should i.e. not do owings for S8s willy nilly, do their due diligence and obtain a legal script, then there wouldn’t be a problem in the first place. It’s not legal, its as simple as that. The doctors would have to comply with requirements and issue a timely script, because there is no other option, as no pharmacist should meet their incomplete order. Issuing a script without all of its requirement is like us dispensing a medication without the label. The onus would be on the doctor NOT the pharmacist for failing to fulfill care. I think once this happens they will quickly clean up their act.

      Pharmacists have spoiled doctors in not writing prescriptions properly and it has led to this inconsistency where they now don’t know how to issue a valid prescription. If they’re not pulled up on it, they’ll keep doing it because they don’t know or feel they don’t have to.

      Too many times have I had to educate doctors on how to write a S8 script correctly, too many times have I been told that they have been writing scripts the way they have (wrong) for decades without anyone saying anything and questioned about why I am wasting their time. Pharmacists only have themselves to blame if they keep allowing it.

      The Guild or PSA should run a workshop with pharmacists, if anything as there are clearly pharmacists out there that do not understand this and allow this practice to happen in the first place.

      In every instance this consumes a lot of my time attempting to verify, reconcile and re-educate doctors. Whilst it is frustrating that doctors are ignorant to it or get hostile about the situation, it’s even more so that other pharmacists allow it.

      One thing is clear, this is happening because we are not being consistent in enforcing this as pharmacists. We can try to tell doctors all we want with workshops and seminars, but at the end of the day if we keep allowing it to happen, itll keep happening.

      • Jarrod McMaugh

        We need more capacity to upvote this comment.

        Very good overview of the issue Steven. 100% correct

      • Apotheke

        Problem is Steven there is a major power imbalance between doctors and Pharmacists. Doctors frequently tell their patients the dispensed price of medications from their MIMs which is often months if not years out of date. They tell them to shop around for the “best price” on private prescriptions often directing them to BIG box discounters such as CWH as it is the best known operator in this space. This is all in the name of “saving the patient money” on those expensive prescription drugs and OTC items. This is all an effort to appear to act in the patient’s “best interests”. Doctors would take offence if Pharmacists told them how to run their medical practices and what to charge their patients but doctors seem to have no problem doing the reverse and often harming a Pharmacist’s business by what they tell their patients. We Pharmacists have no such power so must of us just accept this reality and do our best not to offend the almighty prescribers in our immediate area.

        • Steven Ung

          I think we have under utilised powers that pharmacists forget to exercise. We have the power to refuse supply of an order if it does not pass our clinical or legal appraisal and judgement.

          A doctor may choose to disagree with information an individual pharmacist presents to him/her. That is their decision. However, if every pharmacist refuses supply from their invalid order then who really has the power? If no pharmacist is willing to supply from a doctor’s invalid order then the patient will eventually return to the doctor, as the problem lies with them. When a pharmacist succumbs to pressure is when they potentially enable the wrong thing to happen. This defeats the purpose of our role and voids our autonomy.

          Looking at Jarrod’s example above, I respect and appreciate his refusal of that doctor’s order. However, I have little doubt the next pharmacist that was presented with that situation filled the order. It’s a deep issue seeded in our profession. We are our own enemy in situations like this. Pharmacists need to know when to say no.

          If we look at this “power imbalance” in a clinical context, for example the recent methotrexate mishap that resulted in an unnecessary death. That script did not pass the pharmacist’s clinical appraisal. However, due to the perceived power struggle, it ended up in the patient’s hands and resulted in the worst outcome.

          We have the capacity as pharmacists to influence decision making. You just have to stand your ground and hope the next pharmacist does too.

          • Jarrod McMaugh

            Steven, the next pharmacy did indeed dispense the same medications that day.

            About 3 days after this instance, we received the last faxed script we had filled (the only legal way to dispense an “owing” schedule 8 item).

            When we entered the script, SafeScript showed the patient had had ALL of their schedule 8 medicines dispensed on the day in question.

            It has been taken further.

      • Ex-Pharmacist

        With the majority of dispensing community pharmacists on ~$28 to $32/hour in script sausage factories around the country, your plea for pharmacists to “practice the way they should” and “be consistent in enforcement” is futile.

  3. Kristine Hall

    The above comments focus on the issue of owing scripts for S8 drugs. The great majority of pharmacists are comfortable asserting the need for a legal script in this example. What does not attract comment (and is often accepted practice) is the issue of owing scripts for S4 drugs. These are medication misadventures waiting to happen…

    • Gavin Mingay

      With which particular drugs are you thinking?

    • Paul Sapardanis

      Kristine this is true but their is provision to provide a 3 day emergency supply. This should only be done for continuation of therapy. I am comfortable doing this as this is better than stopping therapy for certain conditions.

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